Characteristics and long-term surgical outcomes of horizontal strabismus.

PURPOSE: Our aim was to report the characteristics and long-term surgical outcomes of three subgroups of horizontal strabismus in a single institution (divided by strabismus subtype) in a developing country and look into pre-operative factors predictive of surgical success. METHODS: Two hundred and forty-four complete charts of patients, divided into 152 esotropes (ET) and 92 exotropes (XT) who had undergone horizontal strabismus surgeries, were retrospectively reviewed. Charts of patients with muscle palsy, Duane syndrome and consecutive strabismus were excluded; 172 patients were included divided into partially accommodative ET, congenital ET and intermittent XT. Surgical success was defined as a post-operative angle deviation of 12 prism diopters or less. RESULTS: The mean follow-up period of all patients was 31.64 ± 23.12 months. The subgroups were divided into partially accommodative ET (60 patients), congenital ET (60 patients), and intermittent XT (52 patients). Esotropes (both partially accommodative and congenital) presented earlier (p < 0.001). Also, partially accommodative ET had a significantly higher spherical equivalent (SE) compared to congenital ET patients, who had a higher SE than intermittent XT (p < 0.001). Congenital ET patients had a significantly larger angle of deviation (for both far and near) than both partially accommodative ET and intermittent XT patients (p < 0.001). The overall success rate was 72.67% for the whole group with no significant differences among subgroups. Success rate of partially accommodative ET surgery was 78.33% compared to that of congenital ET at 66.67% and intermittent XT at 73.07%. Significant post-operative improvement in sensory fusion was observed mainly for patients with partially accommodative esotropia and intermittent exotropia. CONCLUSION: Our results showed that esotropes (both partially accommodative and congenital) presented earlier, with a higher spherical equivalent in the partially accommodative ET subgroup, while the congenital ET subgroup had the largest angle of deviation for both distance and near. The overall surgical success rate for horizontal strabismus surgery was 72.67% with the 3 subgroups having similar success rates. A younger age at presentation and absence of amblyopia were positively correlated with surgical success in the partially accommodative esotropia group.

Gene therapy in color vision deficiency: a review.

BACKGROUND: Color vision deficiencies are a group of vision disorders, characterized by abnormal color discrimination. They include red-green color blindness, yellow-blue color blindness and achromatopsia, among others. The deficiencies are caused by mutations in the genes coding for various components of retinal cones. Gene therapy is rising as a promising therapeutic modality. The purpose of this review article is to explore the available literature on gene therapy in the different forms of color vision deficiencies. METHODS: A thorough literature review was performed on PubMed using the keywords: color vision deficiencies, gene therapy, achromatopsia and the various genes responsible for this condition (OPN1LW, OPN1MW, ATF6, CNGA3, CNGB3, GNAT2, PDE6H, and PDE6C). RESULTS: Various adenovirus vectors have been deployed to test the efficacy of gene therapy for achromatopsia in animals and humans. Gene therapy trials in humans and animals targeting mutations in CNGA3 have been performed, demonstrating an improvement in electroretinogram (ERG)-investigated cone cell functionality. Similar outcomes have been reported for experimental studies on other genes (CNGB3, GNAT2, M- and L-opsin). It has also been reported that delivering the genes via intravitreal rather than subretinal injections could be safer. There are currently 3 ongoing human clinical trials for the treatment of achromatopsia due to mutations in CNGB3 and CNGA3. CONCLUSION: Experimental studies and clinical trials generally showed improvement in ERG-investigated cone cell functionality and visually elicited behavior. Gene therapy is a promising novel therapeutic modality in color vision deficiencies.

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.

Establishment of a formal program for retinoblastoma: Feasibility of clinical coordination across borders and impact on outcome.

Retinoblastoma is an ocular tumor that occurs in young children, in either heritable or sporadic manner. The relative rarity of retinoblastoma, and the need for expensive equipment, anesthesia, and pediatric ophthalmologic expertise, are barriers for effective treatment in developing countries. Also, with an average age-adjusted incidence of two to five cases per million children, patient number limits development of local expertise in countries with small populations. Lebanon is a small country with a population of approximately 4.5 million. In 2012, a comprehensive retinoblastoma program was formalized at the Children's Cancer Institute (CCI) at the American University of Beirut Medical Center, and resources were allocated for efficient interdisciplinary coordination to attract patients from neighboring countries such as Syria and Iraq, where such specialized therapy is also lacking. Through this program, care was coordinated across hospitals and borders such that patients would receive scheduled chemotherapy at their institution, and monthly retinal examinations and focal laser therapy at the CCI in Lebanon. Our results show the feasibility of successful collaboration across borders, with excellent patient and physician adherence to treatment plans. This was accompanied by an increase in patient referrals, which enables continued expertise development. However, the majority of patients presented with advanced intraocular disease, necessitating enucleation in 90% of eyes in unilateral cases, and more than 50% of eyes in bilateral cases. Future efforts need to focus on expanding the program that reaches to additional hospitals in both countries, and promoting early diagnosis, for further improvement of globe salvage rates.

ß-blockers in the treatment of periocular infantile hemangioma.

PURPOSE OF REVIEW: To evaluate the medical literature on the use of ß-blockers, through different routes, for the treatment of periorbital infantile hemangiomas and to summarize the recommendations available on dosage and monitoring. RECENT FINDINGS: ß-blockers for the treatment of infantile hemangioma are now considered to be first-line treatment. Growing literature on the role of oral propranolol confirmed its efficacy but also presented its multiple side-effects including hypotension, bradycardia, hypoglycemia, and bronchospasm. No universal guidelines exist concerning pretreatment evaluation, dosage, monitoring, and duration of treatment but different protocols have been created.In the aim of minimizing side-effects, other routes of administration and more selective ß-blockers have emerged. Many studies showed promising results for topical timolol especially in the treatment of superficial hemangiomas. Few studies evaluated intralesional propranolol. Limited data exist on the use of more selective ß-blockers promising similar results to propranolol with fewer side-effects. SUMMARY: Oral ß-blockers are now the mainstay of treatment for periorbital hemangiomas but still with no consensus on their administration and monitoring. The topical form or more selective ß-blockers may be the solution to minimize side-effects.

Patterns of uveitis in children according to age: comparison of visual outcomes and complications in a tertiary center.

BACKGROUND: Uveitis in the pediatric population is uncommon, accounting for 2 to 14% of all uveitis cases, yet resulting in significant ocular morbidity. A number of studies have focused on patterns and complications of uveitis in the pediatric age group (≤ 16 years). In this report, we studied children with uveitis syndromes focusing on demographics, anatomic distribution, etiologies, treatment, and complications. We additionally divided subjects into two age groups to look into any differential characteristics pertaining to the younger age group and the role of amblyopia as a cause of visual loss. METHODS: Retrospective chart review of 80 eyes of 49 uveitis patients aged ≤16 years. Subjects were categorized by age of onset into visually immature (≤8 years) and visually mature group (> 8 years). Data compared between the two age groups included demographics, disease characteristics, visual outcomes and complications. RESULTS: Idiopathic uveitis was the most common diagnosis (51%). Anterior uveitis complications (posterior synechiae and band keratopathy) were more common in the younger group (p = 0.002 and p = 0.03 respectively) while posterior uveitis manifestations (vitreous haze and vasculitis) were more common in the older age group (p = 0.04 and p < 0.001 respectively). Amblyopia was the most common cause of vision loss in the visually immature versus cataract in the visually mature. CONCLUSION: Anterior uveitis and its complications were more common in visually immature group in our cohort. Amblyopia was identified as the main cause of visual loss in the younger population.

Long-term outcomes of Ahmed tube implantation in pediatric glaucoma after multiple surgeries.

PURPOSE: To report success of Ahmed glaucoma valve (AGV) implantation in eyes with pediatric glaucoma and subconjunctival scarring from previous surgeries. METHODS: A retrospective review of pediatric glaucoma patients who underwent AGV implantation after ≥ 2 previous surgeries with conjunctival scarring. Preoperative and postoperative parameters were recorded to study success, defined as intraocular pressure (IOP) < 22 mmHg with or without medications and without serious complications. RESULTS: Eleven eyes of 10 patients were included, and the mean age was 12.7 years. Diagnoses included primary childhood glaucoma, aphakic glaucoma, and anterior segment anomalies. Mean number of prior ocular surgeries was 3.3 (± 1.3). Final mean IOP was 17.5 (± 4.3) mmHg, significantly different from the preoperative mean of 24.8 (± 6.8) mmHg, p = 0.01. Mean number of anti-glaucoma medications also decreased significantly from 2.8 (± 1.5) to 1.4 (± 1.5), p = 0.02. The success rate was 82% at a mean follow-up of 51.6 (± 10.8) months. Complications were minor and transient. CONCLUSION: Subconjunctival scarring did not increase the risk of failure of tube shunt surgery.

Fornix-based versus limbal-based conjunctival trabeculectomy flaps for glaucoma.

BACKGROUND: Glaucoma is one of the leading largely preventable causes of blindness in the world. It usually is addressed first medically with topical intraocular pressure-lowering drops or by laser trabeculoplasty. In cases where such treatment fails, glaucoma-filtering surgery is considered, most commonly trabeculectomy surgery with variations in technique, for example, the type of conjunctival flap (fornix- or limbal-based). In a fornix-based flap, the surgical wound is performed at the corneal limbus; while in a limbal-based flap, the incision is further away. Many studies in the literature compare fornix- and limbal-based trabeculectomy with respect to outcomes and complications. OBJECTIVES: To assess the comparative effectiveness of fornix- versus limbal-based conjunctival flaps in trabeculectomy for adult glaucoma, with a specific focus on intraocular pressure (IOP) control and complications (adverse effects). SEARCH METHODS: We searched CENTRAL (which contains the Cochrane Eyes and Vision Trials Register) (2015, Issue 9), Ovid MEDLINE, Ovid MEDLINE In-Process and Other Non-Indexed Citations, Ovid MEDLINE Daily, Ovid OLDMEDLINE (January 1946 to October 2015), EMBASE (January 1980 to October 2015), Latin American and Caribbean Health Sciences Literature Database (LILACS) (January 1982 to October 2015), the ISRCTN registry (www.isrctn.com/editAdvancedSearch), ClinicalTrials.gov (www.clinicaltrials.gov) and the World Health Organization (WHO) International Clinical Trials Registry Platform (ICTRP) (www.who.int/ictrp/search/en). We did not use any date or language restrictions in the electronic searches for trials. We last searched the electronic databases on 23 October 2015.We reviewed the bibliographic references of identified randomised controlled trials (RCTs) in order to find trials not identified by the electronic searches. We contacted researchers and practitioners active in the field of glaucoma to identify other published and unpublished trials. SELECTION CRITERIA: We included RCTs comparing the benefits and complications of fornix- versus limbal-based trabeculectomy for glaucoma, irrespective of glaucoma type, publication status, and language. We excluded studies on children less than 18 years of age, since wound healing is different in this age group and the rate of bleb scarring postoperatively is high. DATA COLLECTION AND ANALYSIS: Two review authors independently extracted data and assessed trial quality. We contacted study authors for additional information.The primary outcome was the proportion of failed trabeculectomies at 24 months. Failure was defined as the need for repeat surgery or uncontrolled IOP (more than 22 mmHg), despite additional topical/systemic medications. Needling and 5-fluorouracil (5-FU) injections were allowed only during the first six months postoperatively; additional needling or 5-FU injections were considered as failure. Mean post-operative IOP at 12 and 24 months also was recorded. MAIN RESULTS: The review included six trials with a total of 361 participants. Two studies were conducted in America and one each in Germany, Greece, India, and Saudi Arabia. The participants of four trials had open-angle glaucoma; one study included participants with primary open-angle or primary closed-angle glaucoma, and one study did not specify the type of glaucoma. Three studies used a combined procedure (phacotrabeculectomy). Trabeculectomy with mitomycin C (MMC) was performed in four studies, and trabeculectomy with 5-fluorouracil (5-FU) was performed in only one study.None of the included trials reported trabeculectomy failure at 24 months. Only one trial reported the failure rate of trabeculectomy as a late complication. Failure was higher among participants randomised to the limbal-based surgery: 1/50 eyes failed trabeculectomy in the fornix group compared with 3/50 in the limbal group (risk ratio (RR) 0.33, 95% confidence interval (95% CI) 0.04 to 3.10); therefore we are very uncertain as to the relative effect of the two procedures on failure rate.Four studies including 252 participants provided measures of mean IOP at 12 months. In the fornix-based surgeries, mean IOP ranged from 12.5 to 15.5 mmHg and similar results were noted in limbal-based surgeries with mean IOP ranging from 11.7 to 15.1 mmHg without significant difference. Mean difference was 0.44 mmHg (95% CI -0.45 to 1.33) and 0.86 mmHg, (95% CI -0.52 to 2.24) at 12 and 24 months of follow-up, respectively. Neither of these pooled analyses showed a statistically significant difference in IOP between groups (moderate quality of evidence).One trial reported number of anti-glaucoma medications at 24 months of follow-up with no difference noted between surgical groups. However, three trials reported the mean number of anti-glaucoma medications at 12 months of follow-up without significant difference in the mean number of postoperative IOP-lowering medications between the two surgical techniques. Mean difference was 0.02, (95% CI -0.15 to 0.19) at 12 months of follow-up (high quality of evidence).Because of the small numbers of events and total participants, the risk of many reported adverse events were uncertain and those that were found to be statistically significant may have been due to chance.For risk of bias assessment: although all six trials were randomised selection bias was mostly unclear, with unclear random sequence generation in four of the six studies and unclear allocation concealment in five of the six studies. Attrition bias was encountered in only one trial which also suffered from reporting bias. All other trials had an unclear risk of reporting bias as there was no access to study protocols. All included trials were judged to have high risk of detection bias due to lack of masking of the outcomes. Trabeculectomy is quite a standard procedure and unlikely to induce bias due to surgeon 'performance', hence performance bias was not evaluated. AUTHORS' CONCLUSIONS: The main result of this review was that there was uncertainty as to the difference between fornix- and limbal-based trabeculectomy surgeries due to the small number of events and confidence intervals that cross the null. This also applied to postoperative complications, but without any impact on long-term failure rate between the two surgical techniques.

Spectral domain optical coherence tomography in children: normative data and biometric correlations.

BACKGROUND: The aim was to report normative values of retinal nerve fiber layer (RNFL) and macular parameters in children using spectral domain optical coherence tomography (OCT) and to perform correlations with age, refractive error and axial length. METHODS: This was an observational cross-sectional study recruiting 113 healthy children aged 6 to 17 years with no ocular abnormality except refractive error. After a comprehensive eye examination and axial length measurement, RNFL and macular thickness measurements were performed using the Cirrus OCT machine. Main outcome measures were macular volume, macular thickness and RNFL thickness values as well as their correlations with age, refractive error and axial length. Right eyes of all subjects were selected for analysis. RESULTS: One hundred and eight children were included in the study, 65 females and 43 males. Mean age was 10.7+/-3.1 years, average spherical equivalent refraction (SE) was -0.02+/-1.77(-4.25 to +5.00) diopters and average axial length was 23.5+/-1.0 (21.5 to 25.8)mm. Mean RNFL thickness was 95.6+/-8.7 µm, average macular thickness was 279.6+/-12.5 µm, central macular thickness was 249.1+/-20.2 µm, and mean macular volume was 10.1+/-0.5 mm(3). Central macular thickness values were significantly higher in males (p < 0.001). RNFL measurements did not correlate with age but did show a positive correlation with SE. All macular parameters were consistently positively correlated with age and most of them were positively correlated with SE. When controlling for axial length, only the macular inner circle thickness was positively correlated with age. CONCLUSIONS: Using Cirrus OCT, normative RNFL and macular parameters in healthy children below 18 years of age were established; measurements varied by age and gender.

Long-term surgical outcomes of one-muscle vs. two-muscle horizontal strabismus surgery.

PURPOSE: While horizontal strabismus surgery is generally considered to have favorable outcomes, success rates can vary by type of procedure. Our purpose is to compare the long-term outcomes of patients who underwent one-muscle vs. two-muscle horizontal strabismus surgery. METHODS: This is a retrospective study comparing one-muscle to two-muscle strabismus surgery for small to moderate angle horizontal strabismus. Demographic data and eye exam parameters were compared at baseline and postoperatively (6 months up to 6 years). Surgical success was defined as a post-operative angle of 10 PD or less. We also compared outcomes by strabismus type: esotropia vs exotropia and adjusted the analysis for previous strabismus surgery. RESULTS: Out of 89 patients with moderate angle horizontal strabismus (25 PD or less), 17 patients had a one-muscle operation, and 72 patients had two-muscle surgery. The mean age was 14.12 ± 9.30 years and 11.70 ± 11.30 years for the one-muscle and two-muscle groups, respectively (p = .74). The baseline characteristics of both groups were comparable. Follow-up time was 32.82 ± 26.93 months in one-muscle and 37.67 ± 23.81 in two-muscle groups (p = .29). Success rate was 70.6% for the one-muscle group and 68.10% for the two-muscle group (p = .69). Outcomes were similar when divided into esotropia and exotropia. The success rate was not affected by previous strabismus surgeries nor by the initial angle of deviation. CONCLUSION: One-muscle and two-muscle horizontal strabismus surgery had similar long-term outcomes and did not differ by strabismus type nor by angle of deviation.

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 surface complications in children undergoing general anaesthesia: A prospective observational study.

OBJECTIVE: Ophthalmic complications frequently occur after procedures requiring general anaesthesia, but their incidence is widely variable and not well reported in the paediatric population. The aim was to identify the incidence and possible risk factors of postoperative ocular surface complications in a tertiary care centre. METHODS AND ANALYSIS: This is a prospective study for paediatric patients undergoing general anaesthesia. An ophthalmologist performed the ocular examination after surgery. Parameters assessed were tear breakup time, punctate epithelial erosions and corneal abrasions. Multivariate logistic regression model was used to assess risk factors. RESULTS: A total of 108 paediatric patients were recruited, 36.1% showed abnormal corneal finding: 32 (29.6%) had decreased tear breakup time, three (2.7%) had punctate epithelial erosions, three (2.7%) had both punctate epithelial erosions and decreased tear breakup time and one (0.9%) was found to have a unilateral corneal abrasion postoperatively. A higher rate of corneal complications was noted with younger age, prolonged surgery and surgery in the head and neck region. CONCLUSION: The rate of postoperative corneal abnormalities in children undergoing general anaesthesia was 36.1%, associated with younger age, prolonged surgery and surgery in the head and neck region.

The Ophthalmology Workload during the Lebanese Crisis and Pandemic.

PURPOSE: The purpose is to to explore the effects of the Lebanese economic crisis on the ophthalmology workload in Lebanon, and the concomitant influence of the COVID-19-related lockdown and Beirut port explosion. METHODS: Data pertaining to all the clinic visits to the Ophthalmology Department at the American University of Beirut Medical Center between January 01, 2019, and December 31, 2021, were extracted. Completed visits to different subspecialties were used to analyze the different parameters. All parameters were compared across the 3 years. RESULTS: We included 102,810 completed visits in this study. A total decrease of 15.3% occurred in visits between 2019 and 2020. The mean number of patients per month decreased significantly between 2019 and 2020 in retina/uveitis and glaucoma/anterior segment clinics. The same trend was observed in pediatric/neuro-ophthalmology and cornea/refractive surgery, although it did not reach statistical significance. For oculoplastics, the workload actually tended to increase from 2019 to 2021. During the pandemic-related lockdown (March, April, and May 2020), the workload decreased by 37.8% in oculoplastics, 63.4% in pediatric/neuro-ophthalmology, 52.8% in retina/uveitis, 60.2% in cornea/refractive surgery, and 50.7% in glaucoma/anterior segment. After the Beirut port explosion in August 2020, an overall decrease of 30.2% was found in the number of patient visits in all sub-specialties, while the number of patients in oculoplastics remained nearly unchanged. CONCLUSION: The ophthalmology workload was strongly affected by the economic crisis in all subspecialties especially with the pandemic in 2020, except for oculoplastics. During the pandemic, the most affected subspecialty was the pediatric/neuroophthalmology, while oculoplastics was the least affected.

Effect of the COVID-19 Lockdown on Myopia Progression of School-aged Children: A Retrospective Chart Review.

PURPOSE: To study the effect of the coronavirus disease 2019 (COVID-19)-related lockdown on myopia progression of school-aged children, comparing across the years and within different age groups. METHODS: This was a retrospective chart review of school-aged children with myopia who presented to the pediatric ophthalmology clinic at the American University of Beirut between January 2020 and December 2021 (during COVID-19 lockdown). Annual myopia progression rate (back to January 2016) was computed by dividing the absolute value of the spherical equivalent (SE) difference of two consecutive visits by the duration (in years). Demographic data were retrieved. Patients were then divided into three age groups (3 to 10, 11 to 14, and 15 to 18 years) for analysis. RESULTS: A total of 443 charts of myopic school-aged children were reviewed. Their average age was 11.81 ± 3.67 years with an average of 3.85 ± 1.67 visits across the years. The mean myopic SE increased over time: SE in 2021 was significantly higher than the mean SE in 2016, 2017, 2018, and 2019. Mean SE in 2020 was significantly higher than that in 2016 and 2017. There was no statistically significant difference in the mean annual progression (in diopters/year). For the 3 to 10 years group, the annual SE progression tended to be highest for 2020-2021 and 2019-2020 compared to previous years. CONCLUSIONS: Children had more myopia in 2021 and 2020 (during lockdown) compared to previous years. The myopia annual progression tended to be highest in 2020-2021, especially for the younger age group, but the difference was not statistically significant. [J Pediatr Ophthalmol Strabismus. 2023;60(5):353-358.].

Whole-exome screening for primary congenital glaucoma in Lebanon.

PURPOSE: Mutations were previously identified in the CYP1B1 gene in six out of 18 Lebanese families (33%) with primary congenital glaucoma (PCG). The purpose of this study is to determine the frequency and type of pathogenic mutations in other genes and compare to other populations using whole-exome sequencing and perform genotype-phenotype correlations. METHODS: Twelve PCG patients previously negative for CYP1B1/MYOC mutations were subjected to whole-exome sequencing. Targeted screening for glaucoma-associated genes was performed. Candidate variants were verified by Sanger sequencing and evaluated in family members for segregation analysis and in 100 normal controls. Clinical correlations were established as to severity of disease presentation, course, and visual outcomes. RESULTS: Six mutations in known PCG-causing genes were identified in five patients: homozygous mutations in CYP1B1 (p.R368G), LTBP2 (p.E1013G), and TEK (p.T693I), and heterozygous mutations in FOXC1 (p.Q92*), TEK (c.3201-1 G>A), ANGPT1 (p.K186N), and CYP1B1 (p.R368G). Two patients, negative for CYP1B1 in the previous study, were revealed positive in the current study, due to different sets of primers and PCR conditions. Potentially damaging variants were noted in several candidate genes. Except for FOXC1 mutations, all genetic variants described here are novel. Intra-ocular pressure and final optic nerve cup-to-disc ratio were highest in the patient with three mutations in LTBP2/TEK/ANGPT1 genes. CONCLUSION: This study provides new data on the spectrum of mutations of PCG in Lebanon. This highlights the genetic heterogeneity of the Lebanese population, noted for high rates of consanguinity in 50% in this cohort. This study emphasizes the importance of whole-exome sequencing in elucidating new candidate genes for PCG in the Lebanese.

Success of Endoscopic Laser Cyclophotocoagulation vs Repeat Transscleral Treatment after Prior Transscleral Cycloablation.

Aim: To compare the efficacy of endoscopic cyclophotocoagulation (ECP) vs repeat transscleral cyclophotocoagulation (TCP) in eyes with persistent glaucoma despite prior treatment with TCP. Materials and methods: This was a retrospective chart review of glaucoma patients at the American University of Beirut Medical Center over 10 years who underwent ECP or repeat TCP. We reported qualified and complete success; success was defined as postoperative intraocular pressure (IOP) ≤21 mm Hg, with (qualified) or without medications (complete) and without procedure-related complications. Results: This study included 23 eyes of 21 patients with various forms of uncontrolled glaucoma who had failed TCP. A total of 13 eyes of 12 patients underwent ECP with a mean age of 39.9 ± 23.2 years, and 10 eyes of nine patients underwent repeat TCP with a mean age of 27.2 ± 22.6 years. A significant decrease in IOP was observed from 38.5 ± 7.9 mm Hg preoperatively to 25.2 ± 8.8 mm Hg postrepeat TCP (p = 0.006) and from 33.0 ± 9.5 to 12.8 ± 3.9 mm Hg post-ECP (p < 0.001), noted at a mean follow-up time of 39.2 ± 44.4 and 41.5 ± 37.4 months, respectively. The mean number of antiglaucoma medications decreased in the two groups (from 3.8 ± 1.0 preoperatively to 1.8 ± 0.9 postoperatively for ECP and from 3.5 ± 1.3 to 3.1 ± 0.9 postoperatively for TCP); however, the drop was only statistically significant post-ECP. Qualified success was significantly higher after ECP vs repeat TCP (91.7 vs 40%, respectively). Complete success was achieved only in 1/12 (8.3%) eyes in the ECP group. Conclusion: Endoscopic cyclophotocoagulation (ECP) performed in glaucomatous eyes previously treated with transscleral cycloablation provided more IOP control as compared to repeat TCP by directly treating viable tissue in previously skipped ciliary processes and in between processes. Clinical significance: In glaucomatous eyes previously treated with transscleral cycloablation, ECP attained better IOP control than repeat transscleral cycloablation. How to cite this article: Al-Haddad C, Barikian A, Moussawi ZE, et al. Success of Endoscopic Laser Cyclophotocoagulation vs Repeat Transscleral Treatment after Prior Transscleral Cycloablation. J Curr Glaucoma Pract 2023;17(4):191-196.

Noncoding variants alter GATA2 expression in rhombomere 4 motor neurons and cause dominant hereditary congenital facial paresis.

Hereditary congenital facial paresis type 1 (HCFP1) is an autosomal dominant disorder of absent or limited facial movement that maps to chromosome 3q21-q22 and is hypothesized to result from facial branchial motor neuron (FBMN) maldevelopment. In the present study, we report that HCFP1 results from heterozygous duplications within a neuron-specific GATA2 regulatory region that includes two enhancers and one silencer, and from noncoding single-nucleotide variants (SNVs) within the silencer. Some SNVs impair binding of NR2F1 to the silencer in vitro and in vivo and attenuate in vivo enhancer reporter expression in FBMNs. Gata2 and its effector Gata3 are essential for inner-ear efferent neuron (IEE) but not FBMN development. A humanized HCFP1 mouse model extends Gata2 expression, favors the formation of IEEs over FBMNs and is rescued by conditional loss of Gata3. These findings highlight the importance of temporal gene regulation in development and of noncoding variation in rare mendelian disease.

Scleral Perforation as a Complication of Strabismus Surgery: A Literature Review.

The aim of this review was to report the existing literature on the incidence, risk factors, treatment, and outcomes of scleral perforation as a vision-threatening complication of strabismus surgery. The current literature reported an incidence range of scleral perforation/penetration between 3 in 1,000 and 7.8%. Rectus muscle recession was the most commonly mentioned risk factor among the studies. Other risk factors were myopia, previous extraocular muscle surgery, surgeon experience, S-24 needle use, muscle reattachment posterior to the original insertion site, operating on a horizontal rectus muscle, and young age. Different views existed in the literature regarding scleral perforation management. Some ophthalmologists advocated management by cryopexy or indirect ophthalmoscopic laser uniformly, whereas others reserved it for more complicated cases. Antibiotic therapy for endophthalmitis prophylaxis was recommended by one study and shown to be practiced by some ophthalmologists. [J Pediatr Ophthalmol Strabismus. 2022;59(4):214-223.].

A Review of Driving and Binocularity.

Although most jurisdictions allow stereoscopically deficient and monocular individuals to drive, studies regarding these visual components' effects on driving have to date yielded contradicting results. Interviews, record reviews, and experiments have been used to unmask these effects. In interviews, participants with amblyopia reported several difficulties operating automobiles. Record reviews yielded mixed results, with studies revealing an increased crash rate and/or severity in a group of stereoscopically deficient commercial drivers, whereas studies of non-commercial drivers failed to make that association. Furthermore, experimental studies showed that individuals with reduced stereopsis braked earlier and were less likely to crash. With regard to monocularity, real-life experiments failed to demonstrate a poorer driving performance and simulation studies showed that drivers with sudden monocularity were more likely to crash and drive off the road. [J Pediatr Ophthalmol Strabismus. 2022;59(1):6-12.].