Comparison of Digital Retinal Images and Information Tele-Transferred Through the Hala System to Manual Image Transfer of Diabetic Patients from Primary Health Care Centers in Riyadh.

Background: Diabetes is a significant problem in Saudi Arabia, and telemedicine in the form of tele-screening for diabetic retinopathy (DR) is recommended. Introduction: A comparison of the quality of images and information transferred through the Hala system of the Ministry of Health, Saudi Arabia, with images transferred in a survey at Primary Healthcare Centers in Riyadh, Saudi Arabia, was conducted. Methods: A review of health records was undertaken in 2017-2018. Digital retinal images of diabetics were tele-transferred from a diabetes center to the King Khaled Eye Specialist Hospital (KKESH) for review by medical retina specialists (Group I). Similarly, images of diabetic patients that were transferred from seven primary health clinics to KKESH during a survey were used as images for research (Group II). Additional information reviewed for completeness included patient demographics, risk factors of DR, and previous eye surgery. Results: There were 40 images of 40 patients transferred through the Hala system. There were 120 randomly selected images from survey files. There were significantly more poor images from the Hala system (12.5%) than the research survey system (2.4%). There was no significant difference in the severity of DR between groups. The median Rasch score for the images was -0.58 (interquartile range [IQR] -5.6, 2.6) in Group I and 19.7 (IQR 18.3, 19.7) in Group II. The image reader perceived that the quality of digital retinal images was significantly better in images transferred from the research survey compared with those transferred through the Hala DR tele-transfer system. (Mann-Whitney p < 0.001). Conclusions: Digital image capture and supplementary risk factor information require improvement to enhance DR screening using the Hala system.

Perception Among Diabetic Patients of Telescreening for Diabetic Retinopathy.

Purpose: To evaluate the satisfaction of diabetic patients and its determinants of telescreening for diabetic retinopathy (DR) in Saudi Arabia. Methods: This cross-sectional survey was conducted in December 2018 in a diabetes center of Riyadh, Saudi Arabia. Ten questions were asked by the interviewer. A 5-point Likert scale was used to grade patient responses for each question. Rasch analysis was conducted to evaluate the response of the participants. The main outcome variable was the sum of the Logit values of the responses. The Rasch score was also compared among subgroups. Results: Two hundred (n = 200) diabetic patients were interviewed. The median Rasch score of client-perceived benefit of DR telescreening was +14.6 (25% quartile +3.09, minimum; -23.2, maximum; +35.7). A positive attitude of patients regarding DR telescreening was recorded in 159 (79.5%) participants. The perception of telescreening was better in younger diabetic patients than in older diabetic patients (Friedman p < 0.001). The perception was similar in both genders (Mann-Whitney p = 0.3). Diabetic patients from Riyadh and the southern region of Saudi Arabia had significantly more positive perception than those from north and eastern regions (Freedman p < 0.001). Conclusion: Diabetic patients have positive attitude toward tele-DR screening. Their cooperation is likely to be high if large scale tele-DR screening is implemented in the Kingdom.

Fractured dexamethasone implant (OZURDEX®) following intravitreal injection.

Dexamethasone implant (Ozurdex™) is a relatively safe medication with few adverse events can happen. We demonstrate clinical course and images of a rare case of fractured intravitreal Ozurdex™ implant that observed immediately following injection and its final outcome.

Multifocal Choroiditis with Retinal Vasculitis, Optic Neuropathy, and Keratoconus in a Young Saudi Male.

The purpose of this study is to describe an association of unilateral multifocal choroiditis (MFC), retinal vasculitis, optic neuropathy, and bilateral keratoconus in a young Saudi male. A 27-year-old male patient with stable bilateral keratoconus presented with a painless vision loss in his left eye. Ophthalmic examinations revealed multiple foci of idiopathic chorioretinitis, retinal vasculitis, and mild optic disc leakage on fluorescein angiography, all of which resolved on systemic therapy with mycophenolate mofetil and prednisone after 3 months. Systemic medication was stopped after 8 months. One year after presentation, patient's visual acuity has improved and remained stable. Systemic immunomodulatory therapy can be effective in managing and leading to resolution of MFC, retinal vasculitis, and optic disc leak in young patients.

Changing epidemiology of neovascular glaucoma from 2002 to 2012 at King Khaled Eye Specialist Hospital, Saudi Arabia.

PURPOSE: The aim is to present the incidence and determinants of neovascular glaucoma (NVG) in Saudi Arabia. METHODS: A retrospective review of NVG cases (2002-2012) was included to estimate the incidence. The determinants included gender, age, comorbidities, lens status, type of NVG, and visual acuity on presentation. The impact of antiangiogenic therapy on NVG incidence was studied. RESULTS: We studied 597 eyes with NVG. The incidence was 6.6/10,000. It declined from 13/10,000 in 2008-0.1/10,000 in 2012 (P < 0.001). The decline in 2008 coincided with the introduction of intravitreal injection bevacizumab in Saudi Arabia. Males had a significantly higher NVG risk (odds ratio [OR] = 2.2). Diabetes and hypertension were associated with NVG in 88% and 42.7% of cases, respectively. In 377 (72%) diabetic patients, the glycemic control was poor (HbA1C >7%). Visual acuity was 20/20-20/40 in 14 (2%), 20/50-20/200 in 79 (13%), 20/200-20/400 in 456 (76%), and <20/400 in 45 (7%) eyes. Intraocular pressure was higher than 30 mmHg in 438 (73%) eyes. The cup-to-disc (CD) ratio was >0.8 in 86 (14%) eyes. During the early period (2002-2007) and later period (2008-2012), CD ratio (χ2 = 4, P = 0.09) and anterior chamber angle (P = 0.8) were not different. The presence of NVG in contralateral eye (OR = 0.8, P = 0.3) in both periods was similar. CONCLUSIONS: NVG was associated with diabetes in a very large proportion of patients. It was significantly associated with males, and with poor glycemic control and poor vision at presentation. The incidence of NVG declined after the introduction of intravitreal bevacizumab.

Incidence and Risk Factors for Developing Glaucoma Among Patients with Uveitis in a University-based Tertiary Referral Center in Riyadh, Saudi Arabia.

PURPOSE: To investigate the incidence and risk factors of secondary glaucoma among uveitis patients. METHODS: Retrospective review of medical records of 642 patients (1220 eyes). RESULTS: Glaucoma was diagnosed in 169 (13.9%) eyes and was most common in eyes with anterior uveitis (19.1%) (p < 0.001). HLA-B27-positive anterior uveitis (27.6%), Fuchs' uveitis (23.3%), juvenile idiopathic arthritis (23.1%), herpetic uveitis (20.3%), and Vogt-Koyanagi-Harada disease (16.3%) were the leading clinical entities associated with glaucoma (p < 0.001). Significant risk factors at presentation included worse visual acuity, elevated intraocular pressure, keratic precipitates, granulomatous inflammation, anterior chamber reaction≥ 2+, posterior synechiae, and cataract. Female gender and iris nodules significantly predicted the need for glaucoma surgery. Visual outcome was worse in eyes with glaucoma than in eyes without glaucoma. CONCLUSIONS: Incidence of glaucoma differed depending on anatomic and etiologic diagnoses of uveitis. There is a significant association between severity of inflammation at presentation and development of glaucoma.

Patterns of Uveitis in a University-based Tertiary Referral Center in Riyadh, Saudi Arabia.

PURPOSE: To investigate the referral patterns and diagnosis of uveitis in a university-based tertiary referral center in Riyadh, Saudi Arabia. METHODS: We retrospectively reviewed the medical records of 642 patients (1220 eyes). RESULTS: There were 295 (46%) males and 347 (54%) female patients, with a mean age of 36.4 ± 16.1 years at presentation. Panuveitis was most common (47.1%), followed by anterior uveitis (36.8%), posterior uveitis (10.7%), and intermediate uveitis (5.4%). Nongranulomatous (85.2%) and noninfectious (69.3%) were the most frequent types of uveitis. The most identifiable specific diagnoses were Vogt-Koyanagi-Harada (VKH) disease (19.6%), presumed tuberculous uveitis (PTU) (17.8%), Behçet disease (BD) (8.4%), and toxoplasmosis (6.9%). After a mean follow-up period of 31.3 ± 31.5 months, 73.5% of the eyes achieved visual acuity of 20/40 or better. CONCLUSIONS: The most common anatomic diagnosis was panuveitis. VKH disease, PTU, BD, and toxoplasmosis are the most frequently diagnosed entities.

Valsalva retinopathy associated with sexual activity.

A 54-year-old healthy male presented complaining of sudden loss of vision in the right eye. Initial visual acuity was counting fingers. The patient's acute vision loss developed after sexual activity. Color fundus photos and fluorescein angiography were performed showing a large subinternal limiting membrane hemorrhage in the macular area. A 23-gauge sutureless pars plana vitrectomy with brilliant blue assisted internal limiting membrane peeling was performed with best-corrected visual acuity recovery to 20/50 at 6 months of followup.

Pneumatic displacement with perfluoropropane gas and intravitreal tissue plasminogen activator for subretinal subfoveal hemorrhage after focal laser photocoagulation in central serous chorioretinopathy.

Objective. To report the visual and anatomic outcomes of pneumatic displacement with perfluoropropane (C3F8) gas and intravitreal tissue plasminogen activator (IVTPA) for subretinal subfoveal hemorrhage after focal laser photocoagulation in central serous chorioretinopathy (CSCR). Method. Interventional, retrospective case report of one eye (one patient). Outcome measures included visual acuity (VA), central macular thickness (CMT), and size of the lesion at two weeks of followup. Fluorescein angiography (FA) and optical coherent tomography (OCT) were used to measure anatomic outcomes. Results. A 35-year-old man with history of chronic CSCR received focal laser photocoagulation in the right eye two days before presentation. At initial examination, VA was 20/200 (ETDRS chart), CMT was 398 µ, and a subretinal subfoveal hemorrhage was seen. Tissue plasminogen activator (tPA) at a dose of 25 µg/0.1 mL was injected intravitreally before intravitreal C3F8 injection, and prone positioning was indicated postoperatively. At 24 hours, the hemorrhage had been displaced inferiorly and VA improved to 20/100. Two weeks later, VA improved to 20/80, CMT decreased to 225 µ, and the hemorrhage decreased without foveal involvement. Conclusions. The technique seems safe and effective in treating visually significant subretinal subfoveal hemorrhage.

Different patterns of orbital roof involvement by cholesterol granuloma.

Two patients presented with cholesterol granuloma (CG), with completely different patterns of orbital roof involvement. One patient had a large intraorbital cystic CG, whereas the other had a very large intraosseous CG of the frontal bone. The presentation of CG with variable orbital roof involvement highlights the importance of being aware of the clinical characteristics and the imaging features of CG.