Use of potentially inappropriate medication for elderly patients in tertiary care hospital of Riyadh, Saudi Arabia.

Background and objectives: The elderly population is affected by chronic diseases and lifelong medication. The American Geriatrics Society (AGS) Beers Criteria is a comprehensive approach to medication usage in the older population to reduce potentially inappropriate medication (PIM) use. The purpose of this study was to assess the usage of PIMs in elderly patients upon discharge from tertiary care hospital settings in Riyadh, Saudi Arabia, using the AGS Beers Criteria 2019. Methods: The data was obtained from the medical records of 1237 patients (>65 years) who were discharged from medical or surgical wards at two hospitals affiliated with King Abdulaziz Medical City. The data was analyzed to determine the prevalence of PIM prescription, and the proportional odds of the independent factors influencing outcomes were estimated using ordinal regression analysis for criteria 1 and 2, while Binary regression analysis was conducted for criterion 3. Results: There were approximately equal numbers of male and female participants in our study (male: 50.8 % vs. female: 49.2 %). One-third of the patients were above the age of 80 years, with 41 % being between the ages of 70 and 80 years. Moreover, almost 70 % of the samples had chronic illnesses. The overall prevalence of PIMs was 29.2 %, with 11 % of PIMs to be avoided in elderly patients and 17 % to be used with caution in the elderly, while disease-specific PIMs were identified in 1.2 % of the patients. The most common PIM class was proton pump inhibitors (44.41 %), and patients discharged from the surgical unit were more likely to be prescribed PIMs. Proton pump inhibitors (44.41 %) were the most inappropriately prescribed drug class, and patients discharged from the surgical unit were more likely to be prescribed PIMs. Conclusion: The study noticed that male gender, the presence of multiple diseases, and obesity are associated with more than one PIM prescription. There is a need to streamline the surgical department's prescription procedure to eliminate prescription disparities. Prescription monitoring is recommended to avoid medication errors, particularly in patients who are taking multiple medications.

Evaluation of Apixaban safety and effectiveness in morbidly obese patients with atrial fibrillation: a retrospective cohort study.

BACKGROUND: The benefit of apixaban to reduce stroke risk in morbidly obese patients with nonvalvular atrial fibrillation (AF) is still undetermined. The International Society of Thrombosis and Hemostasis recommends avoiding the use of direct oral anticoagulants (DOAC)s in morbidly obese patients (body mass index > 40 or weight > 120 kg) because of limited clinical data. This exploratory study aims to evaluate the effectiveness and safety of using apixaban in morbidly obese (body mass index (BMI) ≥ 40) patients with AF. METHODS: An exploratory retrospective cohort study was conducted at a single-center, including adult patients with non-valvular AF using apixaban between 01/01/2016 and 31/12/2019. Patients were excluded if they were known to have liver cirrhosis Child-Pugh C, mechanical valve, serum creatinine > 1.5 mg/dL, follow up < 3 months, or using apixaban with a dose of ≤5 or > 10 mg/day. Included patients were categorized into two groups based on their BMI (BMI<40 Vs. BMI ≥ 40). The primary outcome was all thrombotic events, while the secondary outcomes were major and minor bleeding after apixaban initiation. Propensity score (PS) matching was used (1:1 ratio) based on the patient's age, gender, and HAS-BLED score. RESULTS: A total of 722 patients were eligible; 254 patients were included after propensity score matching based on the selected criteria. The prevalence of all thrombotic events was similar between the two groups in the first year of apixaban initiation (OR (95%CI): 0.58 (0.13, 2.5), p-value = 0.46). In addition, the odds of developing major and minor bleeding were not statistically significant between the two groups (OR (95%CI): 0.39 (0.07, 2.03), p-value = 0.26 and OR (95%CI): 1.27 (0.56, 2.84), p-value = 0.40), respectively). CONCLUSION: This exploratory study showed similar effectiveness and safety of apixaban use in both morbid and non-morbid obese patients with non-valvular AF. However, a larger randomized controlled trial with a longer follow-up period needs to confirm our findings.

Awareness level of general population regarding keratoconus in Aseer region, Southern of Saudi Arabia.

BACKGROUND: Keratoconus (KC) is a non-inflammatory disease occur to the cornea and cause it to be thin and progressively bulge it into a cone shape which result to blurred vision secondary to irregular astigmatism, frequently eyeglass changing and increase the sensitivity to the bright light, occur usually at second decade of life and stops progressive after fourth decade of life. keratoconus is unknown in aetiology but is a multifactorial disease in causes which divided into genetic and environmental factors, the genetic factors as if patient under ethnic with high prevalence and family history with keratoconus or Atopy. AIM: to assess the general population awareness regarding keratoconus in Aseer region, southern of Saudi Arabia. METHODOLOGY: A descriptive cross-sectional approach was used targeting all population in Aseer region. The study was conducted during the period from January 2019 to May 2020. Data were collected using structured questionnaire included person's socio-demographic data, Participants' Participants' awareness regarding KC. The questionnaire was uploaded online using social media platforms. RESULTS: The study included 638 participants who completed the study questionnaire with mean age of 36.8 ± 11.1 years. Exact of 331 (51.9%) of the participants were males. University level of education was reported by 424 participants (66.5%). Fifty-nine participants (9.2%) reported that they had keratoconus. CONCLUSIONS & RECOMMENDATIONS: In conclusion, the study revealed that public awareness in Aseer region regarding keratoconus was moderately poor with defect regarding treatment modalities and its consequences.

Corneal perforation associated with topically applied gatifloxacin.

PURPOSE: To document the development of corneal perforation after using gatifloxacin to treat inflamed pterygium. METHODS: A 30-year-old man developed corneal perforation after using gatifloxacin to treat inflamed pterygium. RESULTS: After treatment with gatifloxacin was stopped, the perforation was managed by applying cyanoacrylate glue, followed by pterygium excision. CONCLUSIONS: If used in the management of inflamed pterygium, gatifloxacin may predispose patients to corneal perforation.

5-year follow-up of combined non-topography guided photorefractive keratectomy and corneal collagen cross linking for keratoconus.

AIM: To evaluate the visual outcomes of simultaneous non-topography guided photorefractive keratectomy (PRK) and corneal collagen cross-linking (CXL) in eyes with keratoconus 5y after the procedure. METHODS: Prospective, interventional, non-randomized, and non-controlled case series design was used. Sixty eyes of 30 patients (16 males and 14 females; age: 21-41y) with mild, non-progressive (stages 1-2) keratoconus were enrolled. Refraction, uncorrected distance visual acuity (UDVA) and corrected distance visual acuity (CDVA), flat and steep keratometry readings, and adverse events were evaluated preoperatively and postoperatively. Data were collected preoperatively and postoperatively at 3mo, 1, 2, 3, 4, and 5y follow-up visits after combined non-topography-guided PRK with CXL was performed. All patients had at least 5y of follow-up. RESULTS: All study parameters showed a statistically significant improvement at 5y over baseline values. The mean follow-up time was 68.20±4.71mo (range: 60-106mo). Patients showed a significant improvement in UDVA from 1.24±0.79 logMAR prior to combined non-TG-PRK+CXL to 0.06±0.15 logMAR postoperatively at the time of their last follow-up visit. CDVA significantly increased from 0.06±0.19 logMAR preoperatively to 0.03±0.12 logMAR postoperatively. A significant decrease in the mean spherical equivalent (SE) refraction was observed from -2.28±1.8 to -0.79±0.93 diopters (D) (P<0.05), and the manifest sphere decreased from -1.62±1.23 to -0.27±0.21 D (P=0.001). The manifest cylinder significantly decreased from -1.73±0.86 to -0.29±0.34 D postoperatively (P=0.001). The mean steep keratometry was 45.13±1.32 vs 47.28±2.12 D preoperatively (P<0.05), and the preoperative mean steepest keratometry (Kmax) 48.6±3.1 was reduced significantly to 46.8±2.9 postoperatively (P<0.05). CONCLUSION: Combined non-TG-PRK with 15min CXL is an effective and safe option for correcting mild refractive error and improving visual acuity in patients with mild stable keratoconus.

Prevalence of Keratoconus in a Refractive Surgery Population.

OBJECTIVE: This study examined the prevalence of keratoconus among patients who were interested in undergoing refractive surgery. Corneal tomography measurements were used to help detect keratoconus. METHODS: Adult subjects who presented to the private hospital Cataract and Refractive Surgery Unit (Abha, Saudi Arabia) for refractive surgery evaluation were considered for inclusion in this cross-sectional, retrospective study. All subjects were from the Aseer province, a southern, high-altitude region in Saudi Arabia, and presented between January and December 2017. The incidence of keratoconus and other refractive surgery contraindications were examined. RESULTS: A total of 2931 patients were considered for inclusion in analyses. Of these, 2280 patients (77.8%) were not candidates for refractive surgery. These 2280 patients had a mean age of 24.1 ± 6.6 years and 1231 patients (54.0%) were male. Of the subjects who did not undergo refractive surgery, 548 (24%) had keratoconus, 400 (17.5%) were keratoconus suspects, 344 (15.1%) had thin corneas, 321 (14.1%) had high myopia, and 52 (2.3%) had a high astigmatism. An additional 479 subjects (21%) were candidates for refractive surgery, but chose not to undergo a procedure. CONCLUSION: The incidence of keratoconus in Saudi Arabian refractive surgery prospects was 18.7%. Keratoconus was the most common reason for not performing refractive surgery and accounted for 24.0% of cases in which surgery was not performed.

Outcome of treated orbital cellulitis in a tertiary eye care center in the middle East.

PURPOSE: To describe risk factors predisposing patients to orbital cellulitis and potential complications in patients treated at a tertiary eye care referral center in the Middle East. DESIGN: Noncomparative, interventional, retrospective case series. PARTICIPANTS: Patients diagnosed with orbital cellulitis. METHODS: A 15-year clinical review of patients with a diagnosis of orbital cellulitis referred to King Khaled Eye Specialist Hospital, an accredited (Joint Council on Accreditation of Healthcare Organizations, Washington, DC) tertiary care center in Riyadh, Saudi Arabia, was performed. Only those patients who had clinical signs and symptoms or radiologic evidence suggestive of orbital cellulitis were included in the study. MAIN OUTCOME MEASURES: Patient demographics, factors predisposing to orbital cellulitis, and resulting complications. RESULTS: A total of 218 patients (136 male, 82 female) fulfilling the diagnostic criteria for orbital cellulitis were identified. The average age of these patients was 25.7 years (range, 1 month-85 years). On imaging studies, there was evidence of inflammatory or infective changes to orbital structures; orbital abscesses were identified in 116 patients (53%). Sinus disease was the most common predisposing cause in 86 patients (39.4%), followed by trauma in 43 patients (19.7%). All patients received systemic antibiotic treatment before the identification of any responsible organisms. Of the 116 patients with orbital abscess, 101 patients (87%) required drainage. The results of cultures in patients in whom an orbital abscess was drained were positive for 91 patients (90%). The most common microorganisms isolated from the drained abscesses were Staphylococci and Streptococci species. Blood cultures were positive in only 4 patients from whom blood was drawn for cultures. Visual acuity improved in 34 eyes (16.1%) and worsened in 13 eyes (6.2%), including 9 (4.3%) eyes that sustained complete loss of vision, which was attributed to the delay in correct diagnosis and timely intervention (average 28 days vs. 9 days in patients with no loss of vision; P<0.05). There were 9 cases of intracranial extension of orbital abscesses that required either extended treatment with systemic antibiotics alone or in combination with neurosurgical intervention. Most patients received oral antibiotics on discharge for varying periods. There were 6 cases (2.7%) of strabismus and 4 cases (1.8%) of ptosis that persisted after treatment and resolution of orbital cellulitis. CONCLUSIONS: Untreated sinusitis and prior history of orbital trauma were the 2 major causes of orbital cellulitis in patients referred to a tertiary care eye center in the Middle East. Although rare, severe visual loss still remains a serious complication of delayed detection and intervention in most cases of orbital cellulitis.

Long-term use of 0.003% tacrolimus suspension for treatment of vernal keratoconjunctivitis.

PURPOSE: To evaluate the safety and efficacy of 0.003% tacrolimus suspension for the treatment of refractory vernal keratoconjunctivitis (VKC). MATERIALS AND METHODS: This prospective study included 40 eyes of 20 patients with severe VKC. After discontinuing all other medications, patients were treated with varying doses of 0.003% tacrolimus suspension. All were followed for at least 24 months. Changes in signs and symptoms after treatment were evaluated; adverse events were assessed. The clinical response to the treatment was the most important measurement to achieve the conclusion. RESULTS: The mean age of the patients was 15.7 ± 1.4 years. Two patients discontinued treatment due to severe burning sensation and were excluded from the study. Significant improvements in all signs and symptoms, including itching, foreign body sensation, papillae, and Trantas dots, were seen in all patients 6 weeks after starting topical tacrolimus. Itching was the first symptom to improve. Treatment was gradually reduced, and intervals were increasing between applications. Recurrence occurred in all patients who attempted to discontinue treatment. No additional medications were required to provide relief, and no significant changes in visual acuity or refraction were seen. CONCLUSIONS: The safety and efficacy of 0.003% Tacrolimus suspension treatment for refractory VKC were achieved and it can be considered a useful option instead of steroids, despite the poor compliance in few patients due its adverse effects.

Tacrolimus Ointment for Treatment of Vernal Keratoconjunctivitis.

PURPOSE: To evaluate the safety and efficacy of tacrolimus 0.1% ointment for the treatment of refractory vernal keratoconjunctivitis (VKC). MATERIALS AND METHODS: This prospective, nonrandomized case series enrolled 20 patients (40 eyes) with severe VKC, who were treated with tacrolimus 0.1% ointment. The mean age of the patients was 18.25 ± 4.2 years (range, 9-31 years). Each patient completed a follow-up period of at least 24 months. The main outcome measure was the clinical response to treatment. RESULTS: Significant improvements in clinical signs and symptoms were achieved in all patients 6 weeks after starting treatment with topical tacrolimus. Treatment was gradually reduced, with increasing intervals between applications. VKC recurred in all patients who attempted to discontinue treatment. No additional medications were required and no significant changes in visual acuity or refraction were documented. Five patients discontinued treatment due to a severe burning sensation and were excluded from the study. CONCLUSIONS: Tacrolimus, 0.1% ointment, is a safe and effective treatment for VKC refractory to standard treatment and may be used as a substitute for steroid treatments used to controlled disease activity. However, adverse effects could cause poor patient compliance.

Long-term follow-up of tacrolimus ointment for treatment of atopic keratoconjunctivitis.

PURPOSE: To evaluate the long-term clinical outcomes of 0.1% tacrolimus dermatologic ointment (Protopic) in cases of refractory atopic keratoconjunctivitis (AKC). DESIGN: Prospective, nonrandomized, noncontrolled case series. METHODS: Twenty-two eyes from 11 patients with severe AKC who were treated with 0.1% tacrolimus ointment were followed prospectively. The mean age of the patients was 32.27 ± 12.7 years (range, 19-61 years). Each patient completed a follow-up period of at least 48 months, during which the signs and symptoms of AKC were assessed. Changes in the total scores of signs and symptoms from baseline were recorded at each visit, and the main outcome measure was the clinical response to topical tacrolimus treatment. RESULTS: Dramatic improvements in clinical signs and symptoms were achieved 1 week after starting topical tacrolimus treatment, and complete clinical resolution was observed in almost all patients 6 weeks after starting treatment. Treatment was gradually reduced, with increasing intervals between applications. Eight patients remained asymptomatic for up to 3 years, although recurrence occurred in 3 patients who attempted to discontinue treatment. All patients complained of a mild burning sensation upon application of the ointment. No additional medications were required to provide relief, and no patient discontinued treatment because of adverse drug effects. No drug-related ocular complications were encountered, and no significant changes in visual acuity or refraction were documented. CONCLUSIONS: Tacrolimus dermatologic ointment is a potentially safe and effective treatment for AKC cases refractory to standard treatment and may substitute for steroid treatments aimed at controlling disease activity.

Visual outcome of pars plana vitrectomy for retained lens fragments after phacoemulsification.

PURPOSE: To evaluate the visual outcome of patients who underwent pars plana vitrectomy (PPV) for posteriorly dislocated lens fragments after phacoemulsification. METHODS: A retrospective chart review was conducted of all patients who had PPV for posteriorly dislocated lens fragments after phacoemulsification between January 2000 and September 2004 in the Vitreoretinal Service at King Khaled Eye Specialist Hospital, Riyadh, Saudi Arabia. Demographics, preexisting eye diseases, details of the previous cataract surgery, findings at presentation, details of the vitreoretinal procedures, final visual acuity, and complications observed during the follow-up were evaluated. RESULTS: Of the 60 patients identified, 37 patients (37 eyes) had a full set of data and were included in the study. In 21 eyes (56.8%), PPV was performed within 1 week of cataract extraction; in 15 eyes (40.5%), PPV was performed more than 1 week postcataract extraction. An initial visual acuity of 20/200 or worse was found in 34 eyes (91.9%). The final visual acuity was 20/40 or better in 10 eyes (27%), and 20/200 or worse in 13 eyes (35.1%). Retinal detachments were found in 3 eyes (8.1%): 1 before and 2 after vitrectomy. CONCLUSION: There was no statistically significant difference in outcome between those having vitrectomy the first week after cataract surgery and those having it later; however, there was a trend of better visual outcome in early vitrectomy patients (within 1 week).

Resolution of childhood recurrent corneal phlyctenulosis following eradication of an intestinal parasite.

Phlyctenular keratoconjunctivitis is a nodular foreign antigen delayed hypersensitivity reaction typically due to staphylococcal protein (but potentially secondary to antigen from a variety of different organisms, eg, mycobacteria and intestinal worms).(1-4) Conjunctival phlyctens are usually mild and transient, but corneal phlyctens can be severe and recurrent.(3,4) The subject of this report is a severe recurrent unilateral corneal case in a child whose stool was positive for Hymenolepsis nana. Following treatment for the intestinal parasite, the child no longer suffered from recurrent ocular surface inflammation.

Visual recovery after evacuation of orbital emphysema.

Orbital emphysema due to orbital trauma is a well-known occurrence. Visual loss due to orbital emphysema, however, is an uncommon phenomenon. A case of unilateral orbital emphysema following door-handle trauma with subsequent proptosis, painful ophthalmoplegia and compressive optic neuropathy resulting in compromised vision is presented in an 8-year-old male child. Conservative management, including intravenous corticosteroids, failed to resolve the patient's symptoms and compressive optic neuropathy. Surgical intervention to evacuate orbital emphysema resulted in prompt resolution of symptoms, including recovery of vision. A review of the medical literature revealed that only few isolated cases of orbital emphysema with compressive optic neuropathy have been reported previously, with no reports due to door-handle trauma.