Visual outcomes and recurrence rate of macular corneal dystrophy following phototherapeutic keratectomy in Saudi Arabia.

PURPOSE: The purpose of the study was to evaluate the visual outcomes and recurrence rate of patients with macular corneal dystrophy (MCD) who have undergone phototherapeutic keratectomy (PTK). METHODS: This retrospective, single-centered study enrolled patients from King Khaled Eye Specialist Hospital who had undergone PTK for MCD between 2000 and 2020. Pre-, intra-, and post-operative data were collected, and the primary outcome measures included uncorrected visual acuity, best-corrected visual acuity (BCVA), spherical equivalent, central keratometry, keratometric astigmatism, recurrence rate, and necessity of subsequent surgery. RESULTS: This study evaluated 42 eyes of 29 patients. BCVA improved from 0.41 (±0.17) preoperatively to 0.30 (±0.16) postoperatively. Sixteen out of 42 eyes (38%) had the recurrence of macular dystrophy deposits within the stroma; the average time from PTK to recurrence was 37 months (range: 5.5-115.4 months). The overall success rate of PTK at 2 years was 44.8%. Eleven eyes (26%) required subsequent surgery following PTK at an average of 43 months postoperatively. Deeper ablation and longer application of mitomycin C (MMC) were both found to be statistically significant factors associated with visual improvement and lower recurrence rate following PTK. CONCLUSION: PTK can be considered a treatment modality for younger patients to defer keratoplasty to a later stage. Deeper ablation is associated with improved postoperative visual acuity, and longer application of MMC is associated with lower recurrence rates of MCD.

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.

Acute Sterile Keratolysis After Deep Anterior Lamellar Keratoplasty in a Patient With Keratoconus: A Case Report.

PURPOSE: The purpose of this study was to report the outcomes of using gamma-irradiated sterile cornea (GISC) as a deep lamellar keratoplasty (DALK) graft in a patient with keratoconus. METHODS: This is a case report. RESULTS: A 33-year-old male patient diagnosed with keratoconus underwent DALK using a GISC and developed a persistent epithelial defect which eventually led to sterile keratolysis necessitating further surgical interventions. Management and slitlamp photography, anterior segment optical coherence tomography (AS-OCT), and histopathological examination of the explanted graft are described in detail. CONCLUSIONS: This is the first reported case of sterile keratolysis after the use of GISC lenticule in DALK in a healthy patient with keratoconus. The underlying pathophysiology is not clearly understood, and some theories have been proposed in this report. Surgeons need to be aware of this rare complication and are encouraged to have a low threshold for graft replacement to ensure good clinical and visual outcomes. Developing a prospective complication registry to document complications after the use of GISC lenticules in ophthalmic surgery is recommended.

Scleral melt and uveal prolapse following 23-gauge pars plana vitrectomy.

Purpose: To report a case of uncontrolled juvenile open angle glaucoma (JOAG), with secondary high axial myopia who presented with scleral melting and uveal prolapse post pars plana-vitrectomy. Observations: A 17-year-old male juvenile glaucoma patient, not known to have any systemic disease underwent a right eye 23-gauge-pars plana vitrectomy for retinal detachment repair. Three weeks following his surgery he presented complaining of tearing and photophobia in the operated eye in the absence of any ocular pain. Clinical exam revealed enlarged sclerotomy sites with localized conjunctival and episcleral injection, scleral thinning and uveal prolapse. Infectious and serologic work up were obtained to rule out an infectious etiology or underlying autoimmune disease. Patient was successfully managed with topical steroids and a donor scleral patch graft. Conclusion and importance: This report addresses multiple risk factors for a devastating complication that may occur in predisposed patients, with primary or secondary axial myopia and a compromised sclera. This group of patients can be at risk of post-operative scleral melting and thinning and should be identified pre-operatively and monitored closely during their post-operative course.

Impact and Determinants of COVID-19 Pandemic on the Cataract Surgery Rate at a Tertiary Referral Center.

Purpose: Preventive measures to mitigate the spread of coronavirus, minimized workload on health-care systems and redirected resources to COVID-19 patients resulting in a reduction of elective procedures such as cataract surgery. We report the changes in monthly cataract surgery rate and its associated determinants at a tertiary eye hospital during different periods of the pandemic. Studying the impact of COVID-19 pandemic on cataract surgery rate will help health-care policymakers to better understand the barriers to overcome the expected surgical backlog. Methods: A retrospective review of medical records was performed for cataract surgeries from November 2018 to January 2022, five thousand and ninety-two eyes that underwent cataract surgery during different phases of the COVID-19 pandemic were included. The monthly cataract surgery rate (MCSR) was calculated and compared before (Phase 1), during (Phase 2) and after the COVID-19 pandemic (Phase 3 and 4). Changes in monthly cataract surgery rate during and after the pandemic were presented as ratios and compared pre- to post-pandemic levels to evaluate the impact of different determinants. Results: Of 9701 cataract patients, 5092 (52.5%) were operated in P1, 71 (0.73%) in P2, 116 (1.2%) in P3 and 4422 (45.6%) in P4. The MCSR varied significantly based on the degree of visual impairment in the operated and fellow eyes, and by the type of operating surgeon (P < 0.05). Age, gender, laterality, and place of residence were not significantly different throughout the study period. During phase 1135 (2.6%) eyes had rupture of the posterior capsule (PCR), while 6 eyes (8.4%) had PCR in phase 2. Conclusion: The monthly cataract surgery rate declined during the pandemic and has not recovered to pre-pandemic levels. This should alert the key stakeholders to address the identified barriers to surpassing the baseline monthly surgical rate as this is crucial to eliminate the surgical backlog after the pandemic.

Therapeutic potential of the MDM2 inhibitor Nutlin-3 in counteracting SARS-CoV-2 infection of the eye through p53 activation.

Starting from the beginning of the severe acute respiratory syndrome Coronavirus-2 (SARS-CoV-2) global pandemic, most of the published data has concentrated on the respiratory signs and symptoms of Covid-19 infection, underestimating the presence and importance of ocular manifestations, such as conjunctivitis, usually reported in SARS-CoV-2 infected patients. With the present review we intend to resume the ocular involvement in SARS-CoV-2 infection and the recent discoveries about the different cell types and tissues of the eye that can be directly infected by SARS-CoV-2 and propagate the infection. Moreover, reviewing literature data about p53 expression in normal and diseased eye tissues, we hypothesize that the pleiotropic protein p53 present at high levels in cornea, conjunctiva and tear film might play a protective role against SARS-CoV-2 infection. Since p53 can be easily up-regulated by using small molecule non-genotoxic inhibitors of MDM2, we propose that topical use of Nutlin-3, the prototype member of MDM2 inhibitors, might protect the anterior surface of the eye from SARS-CoV-2 infection, reducing the spreading of the virus.

Preliminary Surgical Outcomes of a Trimmed-Plate Aurolab Aqueous Drainage Implant (AADI) in Eyes at High Risk of Hypotony.

Purpose: We describe the technique of trimming the 350 mm2 AADI glaucoma shunt plate and report preliminary results that test the hypothesis that the IOP-lowering efficacy of the trimmed AADI glaucoma shunt is comparable to the Baerveldt 250 mm2 glaucoma drainage implant with a comparable safety profile to the standard AADI implant. Methods: Consecutive patients who had received the modified trimmed-plate AADI, standard AADI and Baerveldt 250 mm2 were included in the study. This included patients with refractory or primary or secondary glaucoma of all ages and eyes with and without previous glaucoma surgery. The decision for trimming the AADI plate was made according to the surgeon's perceived risk of hypotony. Pre-operative, intraoperative and post-operative data were collected from the hospital electronic medical record system. Surgical success was defined as IOP ≥5 mmHg and ≤21 mmHg on two consecutive visits after 3 months, whilst maintaining at least LP vision and avoiding re-operation for glaucoma. Results: The sample consisted of 69 eyes (19 with trimmed-plate AADI implant; 36 eyes with the standard AADI implant and 14 eyes who received a BGI-250). The mean IOP reduction at 1 year was 15 mmHg for the Baerveldt-250, 10 mmHg for the AADI and 13 mmHg for the trimmed-plate AADI. The surgical success rate of the implants over 1 year was 85.7% (95% CI, 53.9-96.2%) for BGI-250, 81.5% (62.6-91.5%) for standard AADI and 78.2% (51.7-91.3%) for the trimmed AADI. Conclusion: Trimming the plate of the AADI manually may provide a safe and low-cost method of obtaining a successful surgical outcome in eyes at high risk of hypotony.

Intermediate-term Visual Outcomes and Complications of Type 1 Boston Keratoprosthesis With and Without Glaucoma Surgery.

PURPOSE: Glaucoma is a cause of comorbidity in patients receiving the Boston keratoprosthesis (KPro). The aim of this study was to report the outcomes of the Boston KPro with or without glaucoma surgery. METHODS: This was a retrospective single-center cohort study. Patients who underwent Boston KPro from March 2009 to February 2019 were included. One eye per patient (the first surgery) was included in this study. Patients were classified into 2 groups: KPro only (group 1) and KPro with any form of glaucoma procedure (group 2). Main outcome measures were Best-corrected visual acuity (BCVA), functional success (BCVA 20/200 or better), anatomical success (retention of KPro at the last follow-up), and complications. RESULTS: Seventy-one eyes were included: 27 eyes (38%) in group 1 and 44 (62%) in group 2. There was no statistically significant difference in BCVA between groups 1 and 2 at each time point. Of the eyes in group 1, 11% lost light perception vision and 4.5% in group 2 ( P = 0.293). There was no difference in anatomical success with 70% in group 1 and 77% in group 2 ( P = 0.703) at the last follow-up, with a median failure time of 18 months. The functional success was 48% for group 1 and 50% for group 2 ( P = 0.541). CONCLUSIONS: Eyes undergoing KPro with glaucoma surgery before or at the same time carry a similar functional and anatomical success to eyes without glaucoma surgery.

Challenges of Glaucoma Management in Patients with Type I Boston Keratoprosthesis.

Type I Boston keratoprosthesis is implanted in patients with severely diseased eyes who are considered poor candidates for traditional keratoplasty. Glaucoma is considered a major visual comorbidity following the implantation of type I Boston keratoprosthesis (KPro). Eyes that receive a Boston KPro are at high risk of progression of pre-existing glaucoma and the development of de novo glaucoma. Both complications can limit best-corrected visual acuity postoperatively. Diagnosis and surveillance for glaucoma in KPro eyes are fundamental to mitigate the risk of visual morbidity. However, managing these patients presents several challenges. The diagnosis of glaucoma after KPro implantation is usually hindered by inaccurate intraocular pressure (IOP) measurements and unreliable ophthalmic investigations such as visual field testing and optical coherence tomography (OCT) of the retinal nerve fiber layer (RNFL). In these eyes, medical management of glaucoma with topical medications is usually insufficient, and glaucoma surgery is usually warranted either prior to or during KPro implantation. Options for glaucoma surgery include glaucoma drainage device (GDD) and cyclodestructive procedures. The aim of this article is to highlight the incidence, pathophysiology, diagnosis, and management options of glaucoma in eyes that have undergone type I Boston keratoprosthesis.

Ophthalmic Features of Spinocerebellar Ataxia Type 7: A Case Report.

BACKGROUND Spinocerebellar ataxia (SCA) is an inherited progressive neurodegenerative disorder characterized by late-onset cerebellar and brainstem dysfunction. It is an autosomal dominant condition with monoallelic pathogenic expansion in the ATXN7 gene. Patients have neurological deficits, including ataxia and dysarthria. Visual symptoms are the first presenting signs in patients with SCA type 7 (SCA7), including severely affected visual acuity and color vision, ocular motility impairment, and retinal macular degeneration. This is one of the first reports of the existence of keratoconus in a patient with SCA7. Few theories explain this coexistence, including vigorous rubbing of the eyes, and genetic and environmental etiologies. CASE REPORT A 34-year-old man with SCA7 underwent genetic and ophthalmic investigations. Multiple family members of the patient had a positive history of ataxia. He had an abnormal posterior and anterior corneal elevation on Pentacam (Pentacam-Oculus, Optikgeräte GmbH, Wetzlar, Germany) and was eventually diagnosed with keratoconus in both eyes, which is not a known feature of SCA7. Later, he underwent a penetrating keratoplasty in the left eye with no subsequent improvement in vision. No further treatment was offered to the patient due to the guarded visual prognosis caused by the retinal pathology. He continues to have routine follow-ups in the Ophthalmology Clinic. CONCLUSIONS This case reinforces the importance of recognizing the guarded visual outcome in these patients due to the macular degeneration and progressive nature of the disease. Therefore, appropriate and adequate patient counseling about the visual prognosis is essential before proceeding with any ocular surgical interventions.

The Ahmed versus Baerveldt Study at King Khaled Eye Specialist Hospital: Three-Year Treatment Outcomes.

PURPOSE: The purpose of this study was to analyze the outcomes of two frequently used surgical valves in treating refractory glaucoma. METHODS: This was a retrospective and nonrandomized study comparing patients aged 18 years or older who underwent implantation using standardized surgical techniques. RESULTS: A total of 86 patients were included in the study, 48 in the Ahmed group and 38 in the Baerveldt group. The overall success rate was 63.1% in both the groups. At the 3-year follow-up, the Ahmed group had a mean intraocular pressure (IOP) of 14.0 ± 4.8 mmHg (60% reduction) compared with 15.8 ± 6.2 mmHg (53.3% reduction) in the Baerveldt group (0.536). The Ahmed group required an average of 1.6 ± 1.3 medications (59% reduction) compared with 2.1 ± 1.7 (40% reduction) in the Baerveldt group (P < 0.001). CONCLUSION: Despite a high failure rate, both devices were effective in lowering IOP and the need for medications. Lower IOP and medications were needed in the Ahmed group.

A preliminary comparison of the Aravind aurolab drainage implant with the Baerveldt glaucoma implant: A matched case-control study.

PURPOSE: The Aurolab® aqueous drainage implant is a low-cost alternative to the Baerveldt glaucoma implant. The aim of this study was to test the hypothesis that the two implants are comparable in terms of surgical success and safety. METHODS: We conducted a retrospective case-control study of Aurolab aqueous drainage implant done at our institution from May 2015 and May 2017. Twenty-five consecutive patients who received an Aurolab aqueous drainage implant were matched by age and diagnosis to patients who received a Baerveldt glaucoma implant. Data were collected pre-operative and post-operative visits, including visual acuity and intraocular pressure, number of medications, and complications. Surgical success was defined as intraocular pressure between 5 and 21 mmHg with a minimum 20% reduction from baseline, without loss of light perception or the need for further glaucoma surgery. Cox regression analysis was used to predict factors associated with surgical success. RESULTS: The median (interquartile range, IQR) intraocular pressure at 1 year was 16.0 (8.0) mmHg for the Baerveldt glaucoma implant and 13.0 (8.0) mmHg for the Aurolab aqueous drainage implant, p = 0.38. Success (mean ± SE) at 1 year for the intraocular pressure >21-mmHg failure criterion was 65% ± 15% for the Baerveldt glaucoma implant and 79% ± 11% for the Aurolab aqueous drainage implant (p = 0.80). The frequency of complications listed was similar for the two groups (Fisher's exact p = 0.71). In the Cox regression, the type of implant was not found to be associated with surgical success. CONCLUSIONS: Our preliminary results suggest that the Aurolab aqueous drainage implant is comparable to the Baerveldt glaucoma implant. Further long-term data in a larger population are needed to confirm these findings.

Preferred Method of Education Among Patients in Ophthalmic Care in Saudi Arabia.

PURPOSE: Educating patients about their diagnosis and proposed management is integral part of healthcare. Often patient noncompliance is due to a lack of knowledge that could result in irreversible ocular damage. In an era where access to information is virtually unlimited, an understanding of the preferred method of eye care education among patients is required for greater effectiveness in lowering morbidity and mortality of diseases. SUBJECTS AND METHODS: Patients visiting the ophthalmology clinics of a tertiary hospital in Riyadh, Saudi Arabia, were interviewed. This cross-sectional study was conducted between December 2014 and March 2015. A representative sample of 200 patients was enrolled. Close-ended questionnaire covering current and client preferred health promotion methods were used to collect clients' response. Data were analyzed with descriptive statistics. RESULTS: Out of the 200 participants, 110 (55%) were males. The majority (n = 154; 77%) listed an ophthalmologist as their current primary source of information regarding their eye condition. Approximately half of the participants (n = 95; 48%) were keen to be educated regarding the causes of the eye disease. The top four educational methods preferred by patients were one-on-one session with an eye care provider (n = 116; 58%), a group session with an eye care provider (n = 30; 15%), an application on a smartphone (n = 53; 27%), video lectures on eye health and diseases (n = 8; 4%). CONCLUSION: Majority of patients in ophthalmic care prefer a one-on-one session with an eye care provider for their eye care education.

Behavior, knowledge, and attitude of surgeons and patients toward preoperative smoking cessation.

INTRODUCTION: Tobacco smoking is a well-known risk factor for postoperative complications. Quitting smoking prior to surgery helps overcome those complications. PROBLEM: Surgeons' attention for educating their patients about the importance of smoking cessation prior to surgery is one of the most effective ways to reduce smoking-related surgical complications. The extent of advised patients by their surgeons has not been identified. METHODS: A descriptive, comparative cross-sectional study using a survey was conducted in 2013 including eligible patients in King Khalid University Hospital. Simultaneously, 69 surgeons were included. All participant data were randomly collected and analyzed using Chi-square analysis. RESULTS: The frequency of smokers is more in surgical patients (37.5%) when compared to ex-smokers (12.5%) and passive smokers (8.3%), which were ex- and passive smokers, and it demonstrated an increased risk (P = 0.001) for surgery group compared to the nonsurgery group (P = 0.001). When comparing with nonsurgery group, most surgical patients agreed to quit smoking before surgery (95.3%). More than half (58.8%) of the patients said that they have been advised by their treating surgeons to quit smoking before surgery. Concerning the surgeons, 66 nonvascular and nonpediatric surgeons responded to the questionnaire (response rate: 22.83%). The majority of the surgeons (60.9%) were interacting with smoker patients. With regard to smoking cessation, 69.6% surgeons have advised smoker patients to stop smoking for more than 2 weeks before surgery. More than half of the surgeons (53.6%) believed that patients quit smoking after preoperative smoking cessation advice. CONCLUSION: The surgeons and patients who participated in this study were aware that smoking cessation improves outcomes, but most of the surgeons did not provide brief advice about time duration to stop smoking.