Assessment of refractive outcomes in eyes that underwent intraocular lens implantation in the posterior chamber but not "in-the-capsular bag:" A comparative retrospective study.

PURPOSE: The purpose of this study was to report visual and refractive outcomes in eyes that underwent intraocular lens (IOL) fixation in the absence of capsular support. METHODS: This was a retrospective chart review of cases undergoing posterior chamber iris-fixated IOL (IFIOL) and scleral-fixated IOL (SFIOL) implants from June 2014 to March 2020 with more than 3 months of follow-up and having a preoperative best-corrected visual acuity of 20/80 and more. RESULTS: Records of 120 eyes of 112 patients were reviewed. The mean age of the patients was 46.9 ± 22.3 (14.4-98.0) years, and 62% (n = 70) of participants were male. Most of the eyes (102: 85%) were aphakic at the time of surgery. The mean follow-up was 22.95 ± 17.1 months. The efficacy index of sutured IFIOL and glued SFIOL outperformed sutured SFIOL at 3 months and final visits postoperatively (P < 0.001). All techniques studied here resulted in a similar safety index at 3 months (P = 0.4). The mean predictive error (postoperative spherical equivalent refraction minus intended target refraction) was +0.07 ± 1.5 D and -0.12 ± 1.4 D at 3 months and the final postoperative visit, respectively. CONCLUSION: The studied techniques have relatively good visual and refractive outcomes in this series. In addition, techniques involving a small corneal incision with foldable IOL fixation to the iris or scleral tissue have superior efficacy and safety indices compared to creating large corneoscleral wounds for rigid IOL fixation techniques.

Implantable Collamer Lens Subluxation in a Patient with Lenticular Coloboma: A Case Report.

BACKGROUND The efficacy and safety of the implantable collamer lens (ICL) in correcting high astigmatism have been previously reported. They are commonly used as an alternative to laser refractive surgery due to advantages such as leaving the cornea untouched, inducing fewer higher-order aberrations, resulting in better optical and visual quality, and it is a reversible procedure. We aim to present the outcome of ICL in managing anisometropia without cataract in an eye with unilateral lenticular coloboma. CASE REPORT A 27-year-old man with a Marfanoid body habitus was seeking refractive surgery for the correction of high astigmatism in the right eye. On presentation, the best corrected visual acuity was 20/30 and 20/20 in the right eye and left eye, respectively. Slit lamp examination indicated inferior lens coloboma extending from the 5 o'clock to the 7: 30 o'clock position in the right eye, after dilation of pupil. Following a complete refractive work-up, a toric ICL implantation was the presumed suitable surgery. Three weeks postoperatively, central vaulting was low, his ICL subluxated inferiorly, and the previously implanted temporal footplates were resting over the lenticular defect inferiorly. A high-resolution ultrasound biomicroscopy confirmed the presence of a ciliary body (CB) cyst at 9 o'clock position. Urgent explantation of the unstable ICL was performed. CONCLUSIONS This case report emphasizes the challenges and limitations associated with ICL implantation in patients with lenticular colobomas and coexisting CB cyst. Selecting smaller lenticular colobomas and avoiding direct interaction between the weak zonules area and the ICL haptics are important steps to ensure the stability of implanted lens.

State of the Art of Pharmacological Activators of p53 in Ocular Malignancies.

The pivotal role of p53 in the regulation of a vast array of cellular functions has been the subject of extensive research. The biological activity of p53 is not strictly limited to cell cycle arrest but also includes the regulation of homeostasis, DNA repair, apoptosis, and senescence. Thus, mutations in the p53 gene with loss of function represent one of the major mechanisms for cancer development. As expected, due to its key role, p53 is expressed throughout the human body including the eye. Specifically, altered p53 signaling pathways have been implicated in the development of conjunctival and corneal tumors, retinoblastoma, uveal melanoma, and intraocular melanoma. As non-selective cancer chemotherapies as well as ionizing radiation can be associated with either poor efficacy or dose-limiting toxicities in the eye, reconstitution of the p53 signaling pathway currently represents an attractive target for cancer therapy. The present review discusses the role of p53 in the pathogenesis of these ocular tumors and outlines the various pharmacological activators of p53 that are currently under investigation for the treatment of ocular malignancies.

Presumed Unindicated Implantation of Posterior Chamber Phakic Intraocular Lens.

BACKGROUND Refractive surgery is one of the most frequently performed ocular surgeries worldwide. Implantation of the posterior chamber phakic intraocular lens has advantages over laser vision correction, especially in high refractive error cases. We present a case of a young adult women with poor vision who underwent bilateral posterior chamber phakic intraocular lens explantation due to high vault, shallow anterior chambers, and a picture of cone-rod dystrophy. CASE REPORT A 23-year-old woman was referred for poor vision following an implantation of bilateral toric implantable collamer lens (ICL) implantation when she was 18 years old for high myopic astigmatism and anisometropia. On presentation, the best corrected visual acuity was 4-6/200 and 2-3/200 in the right eye and left eye, respectively. Slit lamp examination indicated a clear cornea with pigment deposition on the endothelium, high ICL vault, shallow anterior chamber, and bowing of the iris bilaterally. The patient underwent bilateral removal of the ICLs on separate visits, yet the vision remained unchanged. Diagnostics revealed that the patient had bull's eye maculopathy with atrophy due to her cone-rod dystrophy, which caused the poor vision. CONCLUSIONS This report emphasizes the need for careful and appropriate patient and intraocular size selection for refractive surgery. It indicates the importance of thorough medical examination, including genetic testing, fundus examination, and optical coherence tomography when retinal dystrophy is suspected. Generally, close follow-up is crucial in the setting of high vaulting following ICL implantation to prevent secondary complications.

Acute Sterile Keratolysis After Deep Anterior Lamellar Keratoplasty in a Patient With Keratoconus: A Case Report.

PURPOSE: The purpose of this study was to report the outcomes of using gamma-irradiated sterile cornea (GISC) as a deep lamellar keratoplasty (DALK) graft in a patient with keratoconus. METHODS: This is a case report. RESULTS: A 33-year-old male patient diagnosed with keratoconus underwent DALK using a GISC and developed a persistent epithelial defect which eventually led to sterile keratolysis necessitating further surgical interventions. Management and slitlamp photography, anterior segment optical coherence tomography (AS-OCT), and histopathological examination of the explanted graft are described in detail. CONCLUSIONS: This is the first reported case of sterile keratolysis after the use of GISC lenticule in DALK in a healthy patient with keratoconus. The underlying pathophysiology is not clearly understood, and some theories have been proposed in this report. Surgeons need to be aware of this rare complication and are encouraged to have a low threshold for graft replacement to ensure good clinical and visual outcomes. Developing a prospective complication registry to document complications after the use of GISC lenticules in ophthalmic surgery is recommended.

Impact and Determinants of COVID-19 Pandemic on the Cataract Surgery Rate at a Tertiary Referral Center.

Purpose: Preventive measures to mitigate the spread of coronavirus, minimized workload on health-care systems and redirected resources to COVID-19 patients resulting in a reduction of elective procedures such as cataract surgery. We report the changes in monthly cataract surgery rate and its associated determinants at a tertiary eye hospital during different periods of the pandemic. Studying the impact of COVID-19 pandemic on cataract surgery rate will help health-care policymakers to better understand the barriers to overcome the expected surgical backlog. Methods: A retrospective review of medical records was performed for cataract surgeries from November 2018 to January 2022, five thousand and ninety-two eyes that underwent cataract surgery during different phases of the COVID-19 pandemic were included. The monthly cataract surgery rate (MCSR) was calculated and compared before (Phase 1), during (Phase 2) and after the COVID-19 pandemic (Phase 3 and 4). Changes in monthly cataract surgery rate during and after the pandemic were presented as ratios and compared pre- to post-pandemic levels to evaluate the impact of different determinants. Results: Of 9701 cataract patients, 5092 (52.5%) were operated in P1, 71 (0.73%) in P2, 116 (1.2%) in P3 and 4422 (45.6%) in P4. The MCSR varied significantly based on the degree of visual impairment in the operated and fellow eyes, and by the type of operating surgeon (P < 0.05). Age, gender, laterality, and place of residence were not significantly different throughout the study period. During phase 1135 (2.6%) eyes had rupture of the posterior capsule (PCR), while 6 eyes (8.4%) had PCR in phase 2. Conclusion: The monthly cataract surgery rate declined during the pandemic and has not recovered to pre-pandemic levels. This should alert the key stakeholders to address the identified barriers to surpassing the baseline monthly surgical rate as this is crucial to eliminate the surgical backlog after the pandemic.

MDM2 inhibitors-mediated disruption of mitochondrial metabolism: A novel therapeutic strategy for retinoblastoma.

MDM2 is the principal inhibitor of p53, and MDM2 inhibitors can disrupt the physical interaction between MDM2 and p53. The half-life of p53 is very short in normal cells and tissues, and an uncontrolled increase in p53 levels has potential harmful effects. It has been shown that p53 is frequently mutated in most cancers; however, p53 mutations are rare in retinoblastoma. Therefore, therapeutic strategies aimed at increasing the expression levels of wild-type p53 are attractive. In this minireview, we discuss the potential use of nutlin-3, the prototype small molecule inhibitor that disrupts the MDM2-p53 interaction, for the treatment of retinoblastoma. Although p53 has pleiotropic biological effects, the functions of p53 depend on its sub-cellular localization. In the nucleus, p53 induces the transcription of a vast array of genes, while in mitochondria, p53 regulates mitochondrial metabolism. This review also discusses the relative contribution of p53-mediated gene transcription and mitochondrial perturbation for retinoblastoma treatment.

Risk factors, complications, and outcomes of phacoemulsification cataract surgery complicated by retained lens fragments in Asian eyes: A 10-year retrospective study.

PURPOSE: To study the risk factors, visual outcomes, and sequelae of phacoemulsification surgery complicated by retained lens fragments (RLFs). METHODS: This single-center case-control study enrolled consecutive eyes complicated by RLF and compared them to age- and gender-matched uneventful cataract surgery cases at a tertiary care teaching hospital. Biometric, intraoperative, and postoperative data were collected. The primary outcome measures were risk factors, visual outcomes, and rate of postoperative complications. RESULTS: The study and control groups included 282 and 289 eyes, respectively. The estimated incidence of RLF was 1.47% during the study. We found a statistically higher risk of RLF among diabetics (P < 0.001), those with a history of intravitreal injections (P = 0.001), eyes with dense nuclear sclerosis, anterior capsular cataract (P < 0.001), and posterior polar cataract (P = 0.01). There was a statistically higher risk of RLF in eyes with a higher mean preoperative visual acuity (logarithm of the minimum angle of resolution) (P < 0.001) and in cases performed by trainees (P < 0.001). Most eyes in the RLF group (n = 207, 73.4%) retained their preoperative vision or experienced a one-line improvement in visual acuity and 14 eyes (5.3%) experienced more than one-line improvement in vision. CONCLUSION: Although RLFs are rare, they can affect the quality of postoperative vision and outcomes of complicated phacoemulsification surgery.

Long-term outcomes and causes of intrastromal corneal ring segment explantation in a tertiary eye hospital.

PURPOSE: To evaluate the causes and long-term outcomes after intrastromal corneal ring segment (ICRS) explantation in the King Khaled Eye Specialist Hospital. METHODS: This was retrospective cohort study. Two groups were analyzed: Group one, ICRS surgery done in our hospital (n = 41) and group two, surgery done outside but removed in our hospital (n = 29). Causes and postoperative management after ICRS removal were analyzed. For statistical analysis, groups were analyzed into two subgroups of causes of ICRS removal: Visual disturbance versus extrusion/infection/neovascularization (NV) subgroups; and two subgroups of postoperative treatment: Corneal transplant (CT) versus Contact lens (CL)/eyeglasses subgroups. RESULTS: The most common cause of ICRS removal in group one was visual disturbance (45.2%) while in group two was extrusion (41.2%). CL is the preferable management after explantation. 76% of ICRS removal occurred during the first 4 years. In group 1, there was significant worse preimplantation visual acuity (P = 0.02) in CT subgroup versus CL/eyeglasses. CT subgroup had lower pachymetry of 437.4 µm (P = 0.04) and higher myopia of 8.05 (P = 0.03) than CL/eyeglasses subgroup. For group two, there was a significant improvement in uncorrected visual acuity in visual disturbances subgroup after explantation (P = 0.004). After explantation, visual disturbances subgroup had higher myopia -4.4 than extrusion subgroup -1.15 (P = 0.004). CONCLUSION: Seventy-six percent of ICRS removal occurred during the first 4 years. High myopia and pachymetry lower than 437 um were associated with visual disturbances and further management with corneal transplantation. High myopia was also associated with visual disturbances in surgeries done outside our hospital.

Clinical features and histopathological analysis of corneal myxoma.

To describe the presentation, histopathological characteristics, and management outcomes for corneal myxoma. This one-armed cohort study evaluated histologically confirmed consecutive cases of corneal myxoma. Data were evaluated on demographics, clinical presentation, management, histopathological and immunohistochemical features, and outcomes; visual acuity and corneal clarity. The study sample was comprised of 10 eyes (10 patients). The median age at presentation was 10.5 years. Five eyes had high intraocular pressure, four eyes had decreased distance visual acuity and one eye became discolored. Surgical management included penetrating keratoplasty (8 eyes), phototherapeutic keratectomy (1 eye), and evisceration because of a blind painful eye (1 eye). Postoperative best-corrected distance vision ranged from 20/20 to 20/60 (1 eye), < 20/60 to 20/200 (2 eyes), < 20/200 to 20/400 (1 eye), < 20/200 to light perception (4 eyes) and no light perception (1 eye). The histopathology of these lesions showed typical subepithelial proliferating spindle-shaped cells of mesenchymal origin within a myxoid stroma rich in glycosaminoglycan. The median duration of follow-up was 5 years. Recurrence was observed in an eye that underwent local excision. Corneal myxoma is a rare lesion that is presumably isolated, secondary, and reactive in nature. Surgically management yields reasonably favorable outcomes.

Challenges of Glaucoma Management in Patients with Type I Boston Keratoprosthesis.

Type I Boston keratoprosthesis is implanted in patients with severely diseased eyes who are considered poor candidates for traditional keratoplasty. Glaucoma is considered a major visual comorbidity following the implantation of type I Boston keratoprosthesis (KPro). Eyes that receive a Boston KPro are at high risk of progression of pre-existing glaucoma and the development of de novo glaucoma. Both complications can limit best-corrected visual acuity postoperatively. Diagnosis and surveillance for glaucoma in KPro eyes are fundamental to mitigate the risk of visual morbidity. However, managing these patients presents several challenges. The diagnosis of glaucoma after KPro implantation is usually hindered by inaccurate intraocular pressure (IOP) measurements and unreliable ophthalmic investigations such as visual field testing and optical coherence tomography (OCT) of the retinal nerve fiber layer (RNFL). In these eyes, medical management of glaucoma with topical medications is usually insufficient, and glaucoma surgery is usually warranted either prior to or during KPro implantation. Options for glaucoma surgery include glaucoma drainage device (GDD) and cyclodestructive procedures. The aim of this article is to highlight the incidence, pathophysiology, diagnosis, and management options of glaucoma in eyes that have undergone type I Boston keratoprosthesis.

Clear corneal incision in cataract surgery.

Since the introduction of sutureless clear corneal cataract incisions, the procedure has gained increasing popularity worldwide because it offers several advantages over the traditional sutured scleral tunnels and limbal incisions. Some of these benefits include lack of conjunctival trauma, less discomfort and bleeding, absence of suture-induced astigmatism, and faster visual rehabilitation. However, an increasing incidence of postoperative endophthalmitis after clear corneal cataract surgery has been reported. Different authors have shown a significant increase up to 15-fold in the incidence of endophthalmitis following clear corneal incision compared to scleral tunnels. The aim of this report is to review the advantages and disadvantages of clear corneal incisions in cataract surgery, emphasizing on wound construction recommendations based on published literature.

Induction of endothelial RAGE expression in pterygium.

PURPOSE: Chronic inflammation is a critical process in pterygium development and progression, including promotion of angiogenesis. Vascular endothelial cells (ECs) actively participate in and regulate inflammation. Pterygium research has uncovered multiple inflammatory cytokines that are upregulated, but there has been minimal focus on EC activation. The Receptor for Advanced Glycation Endproducts (RAGE), a major proinflammatory molecule expressed in the vascular endothelium and other cell types, is a major instigator of endothelial cell activation. In this study, we explored the hypothesis that RAGE is upregulated in ECs in pterygium. To this end, we examined RAGE expression and immunolocalization in human pterygium and normal conjunctival tissue, with a particular interest in assessing endothelial RAGE. METHODS: Pterygium specimens were obtained from 25 patients during surgery at the King Khaled Eye Specialist Hospital (KKESH). In the same patients, conjunctiva were obtained from the autograft during surgery. Tissue specimens were formalin-fixed and paraffin-embedded. Tissue sections were analyzed with immunohistochemistry with anti-RAGE antibody. Expression and localization of RAGE were evaluated in pterygium and corresponding conjunctiva. RESULTS: RAGE expression was detected in the vascular endothelium in all pterygium tissue specimens and most conjunctival specimens. Other cell types exhibited expression, notably epithelial cells, fibroblasts, and possibly macrophages. Strikingly, endothelial RAGE expression was increased in 19 of 25 pterygium tissue specimens, compared to the corresponding control conjunctiva. CONCLUSIONS: Our data reveal that RAGE expression is upregulated in vascular endothelial cells in pterygium. RAGE upregulation is an important mechanism by which endothelial cells amplify the overall inflammatory response, and suppression of RAGE has been shown to prevent the progression of some systemic disease processes in experimental models. This suggests that pharmacologic targeting of RAGE, which is already being attempted in clinical trials for some diseases, could be useful in treating pterygium.

Glaucoma and corneal transplant procedures.

Glaucoma after corneal transplantation is a leading cause of ocular morbidity after penetrating keratoplasty. The incidence reported is highly variable and a number of etiologic factors have been identified. A number of treatment options are available; surgical intervention for IOP control is associated with a high incidence of graft failure. IOP elevation is less frequently seen following deep anterior lamellar keratoplasty. Descemet's striping-automated endothelial keratoplasty is also associated with postprocedure intraocular pressure elevation and secondary glaucoma and presents unique surgical challenges in patients with preexisting glaucoma surgeries. Glaucoma exists in up to three-quarters of patients who undergo keratoprosthesis surgery and the management if often challenging. The aim of this paper is to highlight the incidence, etiology, and management of glaucoma following different corneal transplant procedures. It also focuses on the challenges in the diagnosis of glaucoma and intraocular pressure monitoring in this group of patients.

Progressive posterior lenticonus in a patient with alport syndrome.

We report a rare case of Alport syndrome with progressive posterior lenticonus. A 24-year-old male presented to our tertiary eye care center with history of poor vision. At initial presentation, the patient had bilateral anterior lenticonus, posterior subcapsular cataract, and renal failure. The patient was diagnosed with Alport syndrome based on a positive family history of the disease and clinical findings. Further examination revealed progressive posterior lenticonus that was not present initially. The presence of such finding is important because it influences the surgical approach to avoid complications during cataract surgery.

Graft failure: II. Ocular surface complications.

Risk factors for corneal transplantation failure include both immunologic factors, such as graft rejection, corneal neovascularization, and peripheral anterior synechiae, as well as non-immunologic factors, such as ocular surface disorders (OSD) and glaucoma. This review highlights the necessity of having healthy ocular surface epithelia, tears, and eyelids. It presents different types of OSD, their underlying pathology, and their impact on native cornea and corneal grafts. In addition, a range of proposed donor and surgical factors influencing surface integrity following corneal transplant are addressed. Current medical and surgical research, both pre- and post-operative that promise to further improve the outcome of corneal grafts in the context of OSD are discussed.

Decentration and cataract formation 10 years following posterior chamber silicone phakic intraocular lens implantation.

PURPOSE: To report a 10-year follow-up for bilateral implantation of a Chiron Adatomed silicone posterior chamber phakic intraocular lens (PIOL). METHODS: A 32-year-old man presented with bilateral blurred vision and monocular diplopia in the left eye of 2 years' duration. RESULTS: Slit-lamp microscopy showed bilateral anterior subcapsular cataract and temporal PIOL decentration, and no visible space between the PIOL and crystalline lens in the right eye. After explantation of the posterior chamber PIOL, lens aspiration, and IOL implantation, uncorrected visual acuity improved to 20/15 in the right eye. Scanning electron microscopy examination showed denser deposits on the central portion of the back surface when compared with the edges. CONCLUSIONS: Long-term follow up of certain designs of posterior chamber PIOLs may reveal late occurrence of complications. Cataract formation may be related to direct contact between the implanted and crystalline lenses.

Complications and visual outcome of LASIK performed by anterior segment fellows vs experienced faculty supervisors.

PURPOSE: To determine the complication rates and visual outcome of laser-assisted in situ keratomileusis (LASIK) that is performed by anterior segment fellows and to compare their results with the results of their experienced faculty supervisors. DESIGN: A single-center, retrospective, interventional, nonrandomized, comparative case series. METHODS: Chart review of the initial 50 LASIK procedures that were performed by each of 10 anterior segment fellows and the first 50 inclusion criteria-matched, contemporaneously performed cases of four faculty members at the King Khaled Eye Specialist Hospital between March and December 2003. RESULTS: There were no statistically significant differences between fellow and faculty cases with respect to complication rates and final visual outcomes. The fellows were significantly more likely to experience microkeratome-related flap complications during their first 25 cases, compared with their second 25 cases (4.8% vs 1.2%; P = .03). Fellows were significantly more likely to perform enhancements (8.0% vs 2.0%; P = .0002), after which the eyes in their group were more likely to be within 1 diopter of the intended refractive target than those in the faculty group (96.0% vs 91.0%; P = .01). Although not statistically significant, eyes in the fellow group were four-fold (2.0% vs 0.5%) more likely to lose two or more lines of best spectacle corrected visual acuity than those in the faculty group. CONCLUSION: To minimize the adverse impact of complications during the learning curve of novice LASIK surgeons, the introduction of this procedure in a well-structured, supervised setting (such as a subspecialty fellowship training program) is recommended.

Penetrating keratoplasty for macular corneal dystrophy.

PURPOSE: To determine the prognosis of penetrating keratoplasty (PK) for macular corneal dystrophy (MCD). DESIGN: Single-center, retrospective, interventional, noncomparative case series. PARTICIPANTS: One hundred forty-one patients (229 eyes) with MCD. INTERVENTION: Retrospective review of the medical record of every patient who underwent primary PK for histopathologically confirmed MCD at the King Khaled Eye Specialist Hospital between January 1, 1983 and December 31, 2002 and for whom at least 12 months of follow-up is available. MAIN OUTCOME MEASURES: Visual acuity (VA), graft survival, and postoperative complications. RESULTS: After a mean follow-up period of 5.9+/-3.8 years (range, 1-17), the mean best-corrected VA was 20/50. At the most recent visit, 206 (90.0%) grafts were clear, and 23 (10.0%) had failed. Probabilities of graft survival were 98.1% at 1 year, 89.8% at 5 years, 82.1% at 10 years, and 74.1% at 15 years. There was a statistically significant increased likelihood of graft failure if the patient was older than 40 years at the time of surgery (P<0.00003). The differences in graft failure between patients older than 40 and those younger were not attributable to statistically significant differences in duration of follow-up, donor age, or donor endothelial cell counts. Corneal endothelial rejection episodes occurred in 47 (20.0%) grafts, but resulted in irreversible graft failure in only 8 (3.5%) eyes. Eighteen (27.3%) of 66 eyes with a recipient size of > or =7.5 mm developed a graft rejection episode, compared with 27 (16.6%) of 163 eyes with a recipient size of <7.5 mm (P = 0.04). Microbial keratitis occurred in 14 (6.1%) grafts and was more likely to occur in patients over 40 (14.0% vs. 3.0%, P = 0.01). Clinically significant recurrence was observed in 12 (5.2%) grafts, after a mean interval of 84+/-48.2 months, and was directly related to patient age (P = 0.04) and inversely related to donor graft size (P = 0.04). CONCLUSIONS: Good visual results and excellent graft survival can be achieved after PK for MCD. The risk of graft failure is higher in patients older than 40 years.