POSTERIOR SCLERAL INDENTATION IN LONG AXIAL LENGTH EYES (AXIAL LENGTH MORE THAN 34 mm ) TO ASSIST IN PARS PLANA VITRECTOMY AND INTERNAL LIMITING MEMBRANE PEELING IN FULL-THICKNESS MACULAR HOLES.

PURPOSE: To assess a novel surgical technique to perform macular surgery in high myopic eyes, with axial lengths >34 mm, where standard-size intravitreal surgical instruments cannot reach the retinal surface during pars plana vitrectomy for internal limiting membrane peeling in myopic macular holes. METHODS: Five eyes with axial length >34 mm were included in this study. A 7-mm Helvoston retractor was placed under Tenon capsule and guided along the eyeball until an elevation was noticed on the macular area. This elevation shortened the operating distance, temporarily, between the sclerotomy and retinal surface, enabling the use of standard-size intraocular instruments. Preoperative vision and optical coherence tomography were compared with postoperative data and used as markers of anatomical and functional success. RESULTS: Vision improvement and anatomical closure of the macular hole with reattachment of the retina was achieved in all five eyes. No surgical complications associated with this surgical technique were noticed. CONCLUSION: Indenting the macular area from behind the eye globe with a 7-mm Helvoston retractor in a high myopic eye with axial length >34 mm during pars plana vitrectomy is safe and makes surgical procedures, such as internal limiting membrane removal, easier.

Evaluation of lipid layer tear film changes after femtosecond small incision lenticule extraction.

Background: Dry eye disease is common after refractive procedures due to tear film instability. There are several causative factors for tear film instability, but the state of individual components of the tear film is not assessed much in published literature. This article quantifies the lipid layer thickness (LLT) of the tear film using surface interferometry before and after the small incision lenticule extraction (SMILE) refractive procedure. Objectives: This study aimed to evaluate the effects of femtosecond SMILE on the postoperative stability of the LLT of the tear film. Design: This was a prospective, interventional, non-case-control study. Methods: A total of 160 eyes of 80 patients were enrolled in the study. The follow-up period was 6 months after surgery. A noninvasive surface interferometer was used to measure the thickness of the lipid layer before surgery and was repeated at 3 and 6 months after surgery. The main outcome measure was the change in average LLT at 3 and 6 months after SMILE and its statistical significance. Results: There were 48 women and 32 men. Age ranged from 21 to 42 years (mean = 27 ± 6.4). Mean LLT at baseline was [oculus dextrus (OD) = 53.38 (±7.24) nm; oculus sinister (OS) = 52.21 (±6.95) nm], at 3 months [OD = 54.38 (±5.75) nm; OS = 53.26 (±5.70)], and at 6 months [OD = 53.31 (±5.66) nm; OS = 52.39 (±5.94)]. Mean LLT showed mild improvement at 3 months after surgery (OD = 53.38-54.38 mm, p = 0.0417; OS = 52.21-53.26 mm, p = 0.0398). There was no significant change in LLT from the baseline before surgery to levels 6 months after surgery (p = 0.8914 OD; p = 0.7368 OS). Conclusion: The SMILE refractive procedure did not alter the LLT that remained stable and adequate at 6 months postoperative follow-up.

Novel Surgical Pathway for Controlled Access to the Subretinal Space: A Case Series.

Purpose: We report a case series demonstrating a novel technique to access the subretinal space through a trans-scleral approach. Methods: This was a prospective, interventional case series. All 25 cases underwent three-port vitrectomy using CONSTELLATION Vision System (Alcon. Laboratories, Inc., Fort Worth, TX) and NGENUITY 3D Visualization System. In all cases a fourth 25G valved cannula was inserted posteriorly in the vitreous cavity to secure a controlled access to the subretinal space. This route was used to remove subretinal fibrosis, drain subretinal fluid, and inject vital dye to identify an occult retinal break in some cases. Results: In 23 of 25 cases, the retina remained attached postoperatively after a single surgery, and vision improvement was observed. In two cases, the retina was attached after an additional procedure. Although mild subretinal hemorrhage was seen in three cases, no other major complication was observed. Conclusions: Access to the subretinal space by a posteriorly placed fourth valved cannula is safe and helps in subretinal fibrosis removal and drainage of subretinal fluid and can be useful in complicated retinal detachments. Translational Relevance: This case series uses knowledge acquired from developing small gauge microincision instruments for pars plana vitrectomy to present a novel clinical application applicable to difficult, complex retinal surgeries.

Pars plana vitrectomy versus three intravitreal injections of bevacizumab for nontractional diabetic macular edema. A prospective, randomized comparative study.

BACKGROUND: The aim of this study was to compare the effectiveness of pars plana vitrectomy (PPV) and removal of the internal limiting membrane (ILM) with three, monthly, intravitreal bevacizumab (IVB) injections for refractory diabetic macular edema. MATERIALS AND METHODS: This was a prospective, randomized, comparative, interventional study. Forty-four patients were enrolled and randomized in two groups. Twenty-two eyes enrolled in Group I received three IVB injections at monthly interval. Twenty-two eyes were enrolled in Group II which underwent PPV with ILM removal. The primary outcomes measured were: (1) Best corrected logMAR visual acuity (BCVA) using Snellen's visual acuity chart. (2) Central macular thickness (CMT) on optical coherence tomography. The secondary outcome measures were: Complication rates like (1) progression of lens opacities, (2) high intraocular pressure needing further treatment/procedure, (3) development of vitreous hemorrhage related to the procedure employed, (4) retinal detachment and (5) severe inflammation/endophthalmitis. RESULTS: In Group I (IVB): 3 (13.6%) eyes showed no change in BCVA; 3 (13.6%) eyes reported decrease in BCVA and 16 (72.8%) eyes showed improvement in BCVA; (P = 0.0181). In Group II (PPV): 4 (18.2%) eyes showed no change in BCVA; 5 (22.7%) eyes showed decrease and 13 (59.1%) eyes showed improvement in BCVA (P = 0.0281). Mean decrease in CMT in IVB group was 108.45 µ, whereas mean decrease in CMT in PPV group was 161.36 µ. No major complications were seen in either group. CONCLUSION: Posttreatment decrease in CMT was more in PPV group and vision improvement more in IVB group. However, no statistically significant difference between the two methods was found.

Structural and functional results of indirect diode laser treatment for retinopathy of prematurity from 1999 to 2003 in Kuwait.

PURPOSE: The purpose was to report the structural, visual, and refractive outcomes of infants treated for retinopathy of prematurity (ROP) with laser and to identify the risk factors for unfavorable outcomes. MATERIALS AND METHODS: The charts of infants with severe ROP treated by diode laser in a tertiary center during the period April 1999 to November 2003 were reviewed. Treated infants were followed up for fundus examination, visual acuity assessment, and cycloplegic refraction. Data regarding ocular risk factors, like zones of ROP and the extent of extraretinal proliferations, and data regarding various systemic risk factors were collected. A minimum follow up of 6 months was needed for inclusion in the study of structural outcome. A minimum follow up of 24 months was needed for the study of visual and refractive outcomes. The outcomes measured were: rate of unfavorable structural outcome, unfavorable visual outcome (visual acuity < 20/40), and high myopia (myopia ≥ 5 diopters). The ocular and systemic risk factors were studied for their significance in the development of unfavorable outcomes. RESULTS: Two hundred seventy eyes of 148 infants were treated for severe ROP, out of which 20 eyes (7.4%) had unfavorable structural outcome. Visual data were available for 149 eyes of 81 infants, of which 70 eyes (47%) had unfavorable visual outcome. Refractive data were available for 131 eyes of 72 infants, and high myopia was present in 23 (17.6%) eyes. Zone I disease was the significant risk factor for unfavorable structural (P < 0.0001), unfavorable visual outcome (P = 0.03), and for high myopia (P < 0.0001). Lower post-conceptional age at treatment was significant for unfavorable structural outcome (P = 0.03) and high myopia (P < 0.0001). Presence of sepsis (P = 0.029) and extraretinal proliferation ≥ 6 hours were significant for unfavorable structural outcome (P = 0.002). CONCLUSION: ROP in zone I was the most significant risk factor for all the unfavorable outcomes. Laser-treated ROP infants need long term follow up.

Endoscope-assisted pars plana vitrectomy in severe ocular trauma.

PURPOSE: To report the results of pars plana vitrectomy (PPV) assisted by ophthalmic endoscope (OE) in severe ocular trauma cases which are unsuitable for PPV using wide-angle contact/non-contact lens due to media haze and/or disorganised anterior segment. METHODS: Prospective, non-comparative, interventional case series. Main outcome measured was anatomic status of the retina postoperatively, secondary outcome measured was functional status regarding vision, intraocular pressure and control of inflammation in cases of endophthalmitis. RESULTS: Fifty trauma cases were included in the study. Out of these, 43 eyes had open globe injuries (32 eyes without intraocular foreign body (IOFB), and 11 eyes with retained IOFB), and seven eyes had post-traumatic endophthalmitis. In the open globe injury group, 36 (83.7%) eyes reported improvement in vision. In endophthalmitis group, five eyes showed improvement in vision. CONCLUSIONS: OE provided a clear view to conduct PPV in select trauma cases where delay in surgery due to hazy media or due to non-availability of donor cornea for simultaneous penetrating keratoplasty can lead to severe proliferative vitreoretinopathy changes.

Results of screening for retinopathy of prematurity in a large nursery in Kuwait: Incidence and risk factors.

AIMS: The aim of the study was to report the incidence of retinopathy of prematurity (ROP) and severe ROP and identify the risk factors for their development in a large nursery in Kuwait. MATERIALS AND METHODS: This was a retrospective, interventional, non-comparative, hospital-based study. Retrospective review of ROP records of premature babies having either birth weight of less than 1501 g or gestational age at birth of 34 weeks or less and born between January 2001 and August 2003. STATISTICAL ANALYSIS: By univariate and multivariate logistic regression analysis. RESULTS: Out of the 599 babies studied, 38.9% developed ROP and 7.8% needed treatment for severe ROP. Multivariate analysis showed low birth weight (OR 13.753, 95% CI 3.66-51.54; ( P < 0.001), gestational age (OR 13.75, 95% CI 3.66-51.54; P < 0.001), surfactant (OR 1.72, 95% CI 1.04-2.83; P = 0.032) and stay in the intensive care unit for longer than 15 days (OR 2.25, 95% CI 1.05-4.85; P = 0.033) to be significant for the development of any ROP. Low birth weight (OR 22.86, 95% CI 3.86-134.82; P = 0.001), bacterial sepsis (OR 3.27, 95% CI 1.51-7.05; P = 0.002) and need for surfactant (OR 4.41, 95% CI 0.94 -20.56; P = 0.059) were found to be the risk factors for severe ROP needing laser treatment. CONCLUSION: The incidence of both any ROP and ROP needing treatment are comparable to other studies. Low birth weight is the most important risk factor for both any ROP and severe ROP.

Accidental Laser Injury to the Eye.

The unprotected human eye is extremely sensitive to laser radiation and can be permanently damaged from direct or reflected beams. Two cases of retinal injury by laser exposure outside hospital setting are reported. Two patients presented in retina clinic in Al-Bahar eye center in Kuwait with complaints of decrease in vision following exposure to unknown light. Case 1 was exposed to a laser used in military warfare and Case 2 exposed to laser pointer. Routine slit lamp examination and fundus examination of the patient was done along with fundus fluorescien angiography (FFA) and Optical coherence tomography (OCT). Patients were followed up in out patient department for 6 months. Patient with military laser exposure had severe permanent vision loss and persisted even after 6 months. Patient exposed to laser pointer beam had transient visual loss, which improved to 20/25 at 7 months follow-up. Laser retinal damage should be suspected in any patient with visual complaints after obvious exposure to unknown strong light. The treatment for laser retinal injuries is extremely limited and hence prevention is essential.

Endophthalmitis after vitrectomy and vitrectomy combined with phacoemulsification: incidence and visual outcomes.

PURPOSE: To study the incidence of endophthalmitis after vitrectomy and after combined vitrectomy and phacoemulsification surgery and to report the results of treatment in such cases. METHODS: This is a retrospective, noncomparative, interventional study based at a tertiary ophthalmology center in Kuwait. Cases of vitrectomy only and combined vitrectomy with phacoemulsification surgery performed during the period from January 1, 1997, to December 31, 2007, were included. Patients undergoing vitrectomy for traumatic etiologies and endophthalmitis were excluded. Patients who developed endophthalmitis after vitrectomy were identified and their records were analyzed. RESULTS: Six patients developed endophthalmitis among 2965 cases of all vitrectomy procedures, resulting in an incidence of 0.20%. The incidence of endophthalmitis was 0.12% for cases undergoing vitrectomy (3 out of 2564 cases) and 0.75% for cases undergoing combined vitrectomy and phacoemulsification surgery (3 out of 401 cases), respectively. Three cases were culture positive. Four cases ended up with final visual acuity of perception of hand movements or worse. CONCLUSIONS: Incidence of endophthalmitis in our series was higher than in other studies. The visual results were poor in 4 out of 6 cases. Earlier diagnosis and more aggressive approach may be needed to improve the results of treatment in these cases.

Efficacy and safety of 1% rimexolone versus 1% prednisolone acetate in the treatment of anterior uveitis--a randomized triple masked study.

PURPOSE: To evaluate the efficacy and safety of 1% rimexolone versus 1% prednisolone acetate ophthalmic suspension in the treatment of anterior uveitis. METHODS: A randomised triple masked, parallel comparison of rimexolone and prednisolone acetate ophthalmic suspensions was carried out on 78 patients with acute, chronic and recurrent anterior uveitis. Treatment regimen included instillation of one or two drops of drug one hourly through the waking hours during the first week, two hourly in the second week, four times a day in the third week, two times a day for the first 4 days and once a day for the 3 days in the last week. The patient was clinically evaluated on the 3-4th, 7-10th, 14th, 21st and 28th days. The patient was also reviewed on the 30th day. Anterior chamber cells and flare reactions were compared for evaluating the efficacy of the drugs. RESULT: Rimexolone is as effective as prednisolone acetate ophthalmic suspension in the treatment of anterior uveitis. The largest difference found was 0.1 in the flare reaction (statistically insignificant; p = 0.3) and 0.2 score units (statistically significant; p = 0.01) in the cells. Overall, comparison of the drugs shows no clinical significance in the treatment of anterior uveitis by either drug. Difference in intraocular pressure (IOP) was also statistically insignificant (p > 0.05). However, three patients in the prednisolone acetate group and 1 patient from the rimexolone group showed a rise in IOP. CONCLUSION: Rimexolone 1% ophthalmic suspension is as effective as and safer than prednisolone acetate 1% ophthalmic suspension in the treatment of anterior uveitis.

Efficacy and reliability of fundus digital camera as a screening tool for diabetic retinopathy in Kuwait.

OBJECTIVE: Many screening and follow-up methods are available for detecting diabetic retinopathy (DR). However, once patients develop retinopathy, it is unclear as to what method should be used for their review. This study is designed to assess the correlation between fundus digital image and clinical examination and to develop a screening program for the early detection of sight-threatening DR using a Canon CF 60 UV fundus camera. METHODS: Patients who were not treated for DR earlier were enrolled in the study. All patients underwent digital fundus photography. The photographs were evaluated and compared with the clinical findings as recorded by retinal specialists. DR and macular edema were analyzed separately, and the correlation was statistically measured. The kappa statistic was used to estimate the extent of the agreement between the two procedures. RESULTS: A total of 92 eyes of 51 patients were eligible to be entered in the study. Comparison of the digital image of the fundus and the examination by an ophthalmologist showed a good correlation. The kappa score for retinopathy was estimated to be 93% with 95.6% concordance. The kappa score for diabetic maculopathy was 88% with concordance of 92.2%. CONCLUSION: We conclude that digital images provide an efficient method for diagnosing and classifying sight-threatening DR, particularly proliferative diabetic retinopathy (PDR). However, agreement between the digital fundus camera and clinical examination by an ophthalmologist for diabetic maculopathy detection, though substantial statistically, was not very satisfactory. It was also felt that the digital photographs can be used as a tool for teleophthalmology and can be integrated as a screening system in Kuwait.