Ophthalmic injuries from the beirut blast: Managing long-term consequences.

The 2020 Beirut Port explosion was one of the largest non-nuclear urban explosions in history, and resulted in a plethora of oculofacial injuries. In this retrospective study, we present the two year follow up ophthalmic outcomes of the survivors of the blast. Only 16 out of 39 patients continued follow up at our center, with 13 having delayed complications and 7 requiring further surgery. The most common delayed complications related to the eyelid, lacrimal system, and orbit. Treatment of disfiguring facial and peri-ocular scarring with laser-assisted drug delivery of topical 5-fluorouracil showed great promise and significantly improved patients' functional and well as cosmetic outcomes.

Multifocal electroretinography in amblyopia.

PURPOSE: To identify whether there are functional abnormalities in the retina of amblyopic eyes using multifocal electroretinography (mfERG). METHODS: This is a prospective study of patients ≥ 7 years of age identified with unilateral amblyopia (strabismic or anisometropic). Multifocal ERG and flash ERG were performed to compare parameters between the amblyopic and non-amblyopic fellow eyes. A complete analysis of the five ring averages was done including the central ring. RESULTS: Thirty-eight patients were included: mean age was 14.3 ± 7.3 years; 18 patients were strabismic and 20 were anisometropic. Amblyopic eye responses across the rings in multifocal ERG were diminished compared with fellow non-amblyopic eyes with significant differences detected in the central rings (p = 0.001). On the other hand, flash ERG did not show any consistently significant differences. When divided by severity, amplitudes of central rings were significantly lower in severely amblyopic eyes compared with non-amblyopic eyes (p = 0.001), while in mild amblyopia, no significant differences were observed. No significant difference was observed between anisometropic and strabismic amblyopic eyes. CONCLUSIONS: Using multifocal ERG, significantly decreased amplitudes were observed in amblyopic eyes compared with normal fellow eyes in the central ring. This correlated with the severity of amblyopia. No difference was observed when comparing the two groups of amblyopia (strabismic and anisometropic). Those findings may help clarify the pathophysiology of amblyopia better and open the door for new objective ways to monitor the response to amblyopia treatment but this needs to be further studied.

Delayed Onset Cranial Nerve Palsies After Endovascular Coil Embolization of Direct Carotid-Cavernous Fistulas.

BACKGROUND: Late recurrence of visual symptoms associated with carotid-cavernous fistula (CCF), including diplopia, is uncommon and raises concern for new or recurrent fistula formation. METHODS: We report 2 patients with traumatic CCFs, where cranial nerve paresis resolved after endovascular CCF treatment only to reappear years later. RESULTS: No evidence of recurrent or new fistula formation was found. Both were treated successfully with strabismus surgery. CONCLUSIONS: Although the cause of delayed onset diplopia after successful treatment is still unknown, theories include late compression of cranial nerves within the cavernous sinus due to coil mass that can cause chronic ischemia, delayed inflammation due to a thrombophilic nidus created by the coil mass, or injury to the cranial nerves that manifests later due to decompensated strabismus.

Arthroscopic Resection of a Bilateral Calcaneonavicular Coalition in a Child.

Calcaneonavicular coalition is a congenital anomaly characterized by a connection between the calcaneus and the navicular. It can manifest as lateral foot pain, peroneal spastic flatfoot, and repeated ankle sprains. Surgery is required in the case of chronic pain and after failure of conservative treatment. The aim of surgical intervention is pain relief and preventing recurrence. Arthroscopic resection is a minimally invasive alternative that has the advantages of quicker recovery and better aesthetic results. This technique has shown significant symptomatic improvement and no recurrence at early follow-up points in a small number of reported cases. The present report presents the case of a child with bilateral calcaneonavicular coalition. This is the first report to our knowledge that describes the outcome of simultaneous bilateral arthroscopic resection of calcaneonavicular coalition in a child with a 2-year follow-up period.

An Emerging Ophthalmology Challenge: A Narrative Review of TikTok Trends Impacting Eye Health Among Children and Adolescents.

In today's digital age, children and teenagers are deeply entrenched in the world of personal electronic devices including laptops, tablets, and smartphones. These serve as gateways to captivate online content. With children as young as 4 years old having access to these gadgets, the potential benefits of technology coexist with many possible risks. One such risk is the growing global issue of myopia. TikTok, a mobile application that gained immense popularity since its inception in 2016, has garnered 1.7 billion active monthly users in 2023 and is expected to reach two billion in 2024. A significant portion of TikTok's user base consists of adolescents, with approximately 41% falling in the 16-24 age group and a third aged 14 or younger. This social media platform has given rise to the phenomenon of "internet challenges," where users complete and share various tasks through videos. While most of these challenges are harmless, some pose serious risks to teenagers who eagerly seek validation and attention from their peers. This manuscript sheds light on a specific subset of TikTok challenges, namely those related to ophthalmological risks. These challenges include "rubbing castor oil trend," "bleach/bright eye challenge," "mucus fishing challenge," "eggsplosions", "beezin challenge", "Orbeez challenge", "blow-drying eyelashes", "sun gazing," and "popping styes". The manuscript emphasizes the importance of monitoring and regulating potentially dangerous content on social media platforms like TikTok. While these platforms offer educational opportunities, they can also promote life-threatening actions, necessitating efforts to protect vulnerable young users and promote safe online engagement.

Modified partial Jensen procedure to treat a hypertropic Knobby eye syndrome in a high myopic monocular patient.

We present a case of severe esotropia and hypertropia in a monocular high myope with an inferolateral staphyloma. Surgery was undertaken to secure the inferior rectus to the lateral rectus via a modified partial Jensen technique, along with medial rectus recession successfully improving head and eye positions and ductions.

Ocular manifestations of severe familial hypercholesterolemia.

Background: To study ocular manifestations of patients with severe familial hypercholesterolemia (FH). Methods: In this population-based case-control study, patients suffering from severe familial hypercholesterolemia from the Lebanese Familial Hypercholesterolemia Registry, along with age and gender-matched healthy controls were recruited. All participants underwent a comprehensive eye examination, and patients underwent fluorescein angiography as well. Logistic regression models were used to identify any association between patients with severe familial hypercholesterolemia and abnormal eye findings, while adjusting for hypertension and pack-year smoking. The main outcome measure of this study was the development of ocular vascular abnormalities. Results: 28 patients and 28 controls were recruited. Patients with severe familial hypercholesterolemia had significantly greater odds of developing corneal arcus and xanthelasmas than the control group (p < 0.001). Retinal vascular abnormalities (plaques) were exclusively and more significantly present in patients with familial hypercholesterolemia (18 %). Similarly, retinal arteriosclerosis was exclusively and significantly more prevalent in the familial hypercholesterolemia group (p < 0.001, adjusted odds ratio 6.8). Stratification by LDL levels and genotypes did not show any significant change in the prevalence of any ocular finding. Conclusion: In addition to the well-established increase in incidence of corneal arcus and xanthelasmas, severe familial hypercholesterolemia patients have more prevalent retinal vascular abnormalities that include vascular plaques and arteriosclerosis.

Impact of online learning during COVID-19 pandemic on digital device related ocular health.

Objective: The aim of this study was to evaluate the impact of the COVID-19 pandemic on ocular health related to digital device usage among university students in Lebanon. Design: A cross-sectional design was utilized to examine the association between the pandemic and ocular health. Participants: A total of 255 university students in Lebanon participated in the study, selected based on their enrollment during the pandemic. Methods: An online survey assessed participants' digital device usage, awareness of digital eye strain, and experienced symptoms. The study addressed the relationship between symptom frequency and screen time, especially in their connection to the pandemic and online learning. Results: Prior to the pandemic, the majority of participants (73.0 %) were unaware of digital eye strain. Following the transition to online learning, nearly half of the participants (47.0 %) reported using digital devices for 12 or more hours. The majority (92.0 %) experienced a substantial increase in daily digital device usage for learning, with an average increase of 3-5 h. Symptoms of digital eye strain, including headache, burning of eyes, blurry vision, sensitivity to light, worsening of vision and dryness of the eyes intensified in both frequency and severity during the pandemic and online learning period. Conclusions: The study emphasizes the importance of promoting healthy habits and implementing preventive measures to reduce the prevalence of digital eye strain symptoms among university students. Healthcare professionals and public health authorities should educate individuals on strategies to alleviate digital eye strain, considering the persistent reliance on digital devices beyond the pandemic.

The yield of neuroimaging in patients presenting to the emergency department with isolated neuro-ophthalmological complaints: A retrospective chart review.

Neuro-ophthalmological emergencies require prompt assessment and management to avoid vision or life-threatening sequelae. The decision to perform a neuroimaging procedure is based on the clinical judgment of the medical team, without defined indications. This study aims to identify presenting symptoms and physical exam findings associated with relative positive findings on neuroimaging studies. Electronic medical records of patients presenting to the emergency department (ED) with isolated neuro-ophthalmologic complaints between January 1, 2013 and September 30, 2019 were reviewed. We collected data on the clinical presentation, neuroimaging procedures and results, consults, and diagnoses. Two hundred eleven patients' charts were reviewed. Most presented with unilateral eye complaints (53.6%), and the most common symptoms were blurred vision (77.3%) and headaches (42.2%). A total of 126 imaging procedures were performed of which 74.6% were normal, while 25.4% showed relevant abnormal findings. Complaining of blurry vision (P = .038) or visual field changes (P = .014) at presentation as well as having a visual field defect (P = .016), abnormal pupil reactivity (P = .028), afferent pupillary defect (P = .018), or abnormal optic disc exam (P = .009) were associated with positive findings on imaging. Neuroimaging is more likely to yield positive findings in patients presenting to the ED with visual field irregularities, afferent pupillary defects, or abnormal optic discs. These findings - when combined with the proper clinical setting - should lower the threshold to proceed with neuroimaging in the emergency department. Based on our results, larger-scale studies might lead to a well-structured algorithm to be followed by ED physicians in decision making.

A comparison of the workload between pediatric and adult ophthalmology encounters.

PURPOSE: To explore the differences in workload between pediatric and adult ophthalmology encounters in the private clinics of an academic medical center. METHODS: Complete encounters from four different subspecialties were analysed: pediatric ophthalmology, pediatric ophthalmology/neuroophthalmology, anterior segment, and retina. Five parameters were studied: time waiting for assistant, time with assistant, time waiting for physician, time with physician, and total visit time. Imaging or procedures performed during the clinic visit were recorded. A regression analysis by age was also performed. RESULTS: Of 8,545 clinic visits reviewed, 5,611 were complete and included. Pediatric patients spent more time than adults with assistants (10.6 ± 11.5 vs 7.3 ± 6.8 min; P < 0.001) and more time with physicians (25.9 ± 21.6 vs 17.0 ± 13.8 min; P < 0.001) but less time waiting for the physician. Total visit time and time waiting for an assistant did not differ significantly between groups. Adults who underwent a procedure or imaging during their visit had significantly longer times in most components of the encounter. Age was positively correlated with time waiting for physician, time with physician, and total visit time in the adult group. In the pediatric group, age was positively correlated with time with assistant and negatively correlated with time with physician. CONCLUSIONS: Our study showed that pediatric patients waited a shorter duration for their physicians than adults; however, they required more time with both the physician and the assistant. Total visit time was similar between groups.

Ophthalmic Injuries After the Port of Beirut Blast-One of Largest Nonnuclear Explosions in History.

IMPORTANCE: A review of the injury patterns, treatment strategies, and responding physicians' experience during the Port of Beirut blast may help guide future ophthalmic disaster response plans. OBJECTIVE: To present the ophthalmic injuries and difficulties encountered as a result of the Port of Beirut blast on August 4, 2020. DESIGN, SETTING, AND PARTICIPANTS: A retrospective medical record review of all patients who presented to the emergency department and 13 ophthalmology outpatient clinics at the American University of Beirut Medical Center for treatment of ophthalmic injuries sustained from the explosion in Port of Beirut, Beirut, Lebanon, from August 4 to the end of November 2020. Patients were identified from emergency records, outpatient records, and operative reports. MAIN OUTCOMES AND MEASURES: Types of ocular injuries, final best-corrected visual acuity, and need for surgical intervention were evaluated. Visual acuity was measured with correction based on noncycloplegic refraction using the Snellen medical record. EXPOSURES: Ocular or ocular adnexal injuries sustained from the Port of Beirut explosion. RESULTS: A total of 39 blast survivors with ocular injuries were included in this study. Twenty-two patients presented with ocular injuries on the day of the blast, and 17 patients presented within the following 3 months to the ophthalmology clinics for a total of 48 eyes of 39 patients were treated secondary to the blast. Thirty-five patients (89.6%) were adults, and 24 (61.5%) were female. A total of 21 patients (53.8%) required surgical intervention, more than half of which were urgently requested on the same day of presentation (14 [35.9%]). Most eye injuries were caused by debris and shrapnel from shattered glass leading to surface injury (26 [54.2%]), eyelid lacerations (20 [41.6%]), orbital fractures (14 [29.2%]), brow lacerations (10 [20.8%]), hyphema (9 [18.8%]), open globe injuries (10 [20.8%]), and other global injuries. Only 7 injured eyes (14.5%) had a final best-corrected visual acuity of less than 20/200, including all 4 open globe injuries with primary no light perception (8.3%) requiring enucleation or evisceration. CONCLUSIONS AND RELEVANCE: In the aftermath of the Port of Beirut explosion, a review of the ophthalmic injuries showed a predominance of shrapnel-based injuries, many of which had a delayed presentation owing to the strain placed on health care services. Reverting to basic approaches was necessary in the context of a malfunctioning electronic medical record system.

Visual Snow: a Potential Cortical Hyperexcitability Syndrome.

OPINION STATEMENT: The purpose of this review is to provide an overview of visual snow (VS) and provide information regarding current treatment options for VS. Visual snow (VS) is a rare disorder manifesting with a persistent visual phenomenon of seeing numerous tiny snow-like dots throughout the visual field, and it can cause debilitating visual and psychological consequences. It is emerging as a disorder separate from, but associated with, migraine visual aura, and neuronal cortical hyperexcitability is being considered as a theoretical mechanism for the persistent-positive visual symptoms. There are few studies that have investigated the treatment of VS, but as our understanding of this entity begins to change, we expect that new treatment approaches and treatment trials will emerge in the next decade. Currently, our approach is to consider pharmacologic treatment for all patients with VS who report decreased quality of life as a result of VS. Resolution of the disorder is difficult to accomplish with treatment, but in our experience, even when symptom intensity is simply reduced, many patients find that there is an improvement in their quality of life that is beneficial. Our preferred treatment options include: (1) oral lamotrigine with a slow increase from 25 mg daily to a maintenance dose of 200-300 mg daily in divided doses as tolerated, and this is typically achieved by advancing the dose in increments of 25-50 mg weekly following the first 2 weeks of therapy; (2) oral acetazolamide with an initial dose of 250 mg daily followed by a slow increase over 1-2 weeks to a total of 1000 mg daily in divided doses, and higher doses can be tolerated by some without increasing the risk-benefit ratio; or (3) oral verapamil long-acting at 120-240 mg daily, and if side effects limit the dose the can be initiated, then lower doses with short-acting verapamil two or three times daily can be substituted until higher doses with the long-acting formula can be tolerated. By initiating drug treatments with low doses and slowly increasing over 1 to 4 weeks, tolerability and compliance improves and allows patients to realize the full benefits of treatment. The proposed mechanisms of microstructural cortical abnormalities and hyperexcitability as a cause of VS may lead to new treatment approaches in the future. Until such a time, medications reported to relieve persistent visual phenomena of migraine and visual aura of migraine are treatment options worth considering and these are reviewed for that purpose. Although clinical trials for the treatment of visual snow are lacking due to the rarity of the disorder, medications reviewed here should be considered for use in patients with VS who experience an impact on their quality of life. Theoretical mechanisms that lead to cortical hyperexcitability are being investigated and could lead to new treatment options. In the meantime, medications may provide benefits in this disabling condition.