Variable presentations of six conjunctival/limbal ocular surface squamous neoplasia (OSSN) cases: How good is our clinical judgment evidenced by the correlation to the histopathological findings and diagnosis?

INTRODUCTION: Ocular surface squamous neoplasia (OSSN) may have atypical or unusual presentations and may attain large sizes especially in cases of delayed presentation resulting in late diagnosis, treatment, and eventual guarded visual prognosis. We are reporting an interesting cases series of OSSN with variable clinical presentations to highlight the importance of the pre-operative clinical judgment and tissue diagnosis. PRESENTATION OF CASES: Six patients (4 females and 2 males; mean age 59 years; range 42-79 years) were included with suspicious conjunctival lesions. The maximum dimension of the lesions was 17 mm. The initial suspected pre-operative clinical diagnosis -other than OSSN- included pterygium/pinguecula (n = 2), benign squamous papilloma (n = 1), cyst versus pyogenic granuloma (n = 1), and lymphoma (n = 1). This work has been reported in line with the PROCESS criteria. DISCUSSION: The final histopathological diagnosis was unexpectedly invasive squamous cell carcinoma (SCC) in 4, one SCC in-situ, and squamous dysplasia in one. The primary treatment included MMC 0.02 % for 2 cycles for chemo-reduction in one of the cases where OSSN was suspected. Excisional biopsy was performed eventually for all lesions with application of one or more of the following modalities: MMC 0.02 %, absolute alcohol 99 %, and cryotherapy to the conjunctival margin. No tumor recurrence was noted in any of the patients after an average period of follow-up of 26 months. Even though the outcome was good, tumor-related morbidity and delay in the referral by general ophthalmologists are to be considered. CONCLUSION: Conjunctival OSSN has wide presentation clinically and can be challenging in terms of diagnosis. Histopathological evaluation is essential for a definitive diagnosis and treatment. Accurate clinical diagnosis might affect the management plan with consideration for topical therapeutic modalities, however, these cases are best managed by wide excision using the no-touch technique and double-freeze-thaw cryotherapy to the conjunctiva with consideration of topical chemotherapy.

Salmon patch-like conjunctival lesion secondary to long-term administration of topical brimonidine: A case report.

INTRODUCTION: Brimonidine is a commonly used intra-ocular pressure-lowering agent for glaucoma patients. Allergic follicular or papillary conjunctivitis is a well-known side effect of brimonidine. Brimonidine is associated with ocular allergic symptoms such as conjunctival hyperemia, stinging sensation, photophobia and, in severe cases, corneal erosions. Here, we report a case of atypical conjunctival lesion following long-term administration of brimonidine. CASE PRESENTATION: We report the clinical findings of a 72-year-old female presenting with a salmon patch-like conjunctival lesion affecting the bulbar and palpebral conjunctiva after long-term use of brimonidine. The finding was suspicious of conjunctival lymphoproliferative disorders. However, upon cessation of brimonidine, along with the administration of short-course topical steroid, a complete resolution of the lesion was evident. Biopsy was not performed as the clinical picture improved with conservative management. No recurrence was observed over 1 year follow up. DISCUSSION: Atypical conjunctival lesions have been described after long-term use of brimonidine. These lesions can mimic the appearance of conjunctival tumors, specifically conjunctival lymphoproliferative disorders, for which multiple investigations are required including invasive conjunctival biopsy. CONCLUSION: Careful observation is recommended for patients with a history of long-term use of brimonidine for the development of atypical conjunctival lesions which may simulate the appearance of conjunctival lymphoproliferative disorders.

New insights into cataract surgery in patients with uveitis: A detailed review of the current literature.

Cataract is a common cause of visual impairment in uveitic eyes. The management of cataract in patients with uveitis is often challenging due to pre-existing ocular comorbidities that may limit the visual outcomes. A meticulous preoperative ophthalmic evaluation is needed to assess the concomitant ocular pathologies with special emphasis on the status of the macula and optic nerve. Preoperative control of inflammation for at least 3 months before surgery is a key prognostic factor for successful surgical outcomes. Perioperative use of systemic and topical corticosteroids along with other immunosuppressive medications is crucial to decrease the risk of postoperative inflammation and cystoid macular edema (CME). Phacoemulsification with intraocular lens implantation is the surgical option of choice for most patients with uveitic cataract. Uveitic cataracts are typically complicated by the presence of posterior synechiae and poor pupil dilation, necessitating manual stretching maneuvers or pupil expansion devices to dilate the pupil intraoperatively. Patients must be closely monitored for postoperative complications such as excessive postoperative inflammation, CME, raised intraocular pressure, hypotony, and other complications. Good outcomes can be achieved in uveitic eyes after cataract extraction with appropriate handling of perioperative inflammation.

Paraneoplastic pemphigus associated with rapidly progressing endophthalmitis caused by Morganella Morganii: A case report.

INTRODUCTION: The ocular presentation of paraneoplastic pemphigus (PNP) has rarely been reported in the literature. In this report, we describe a 61-year-old male presenting with eruptive skin lesions associated with underlying non-Hodgkin's lymphoma who had rapid progressive corneal perforation with secondary endophthalmitis in the setting of PNP. CASE DESCRIPTION: A 61-year-old male presented to the emergency department complaining of skin eruption mimicking Stevens-Johnson syndrome, which was later found to be related to PNP. Initially, the patient complained of progressive ocular surface dryness in both eyes. Meanwhile, he developed mild pain in the right eye associated with blurry vision in both eyes and was managed with lubricants and topical antibiotics. A few days later, he was found to have corneal perforation with features suggestive of left endophthalmitis with possible early panophthalmitis. Intravenous antibiotic was administered, and primary evisceration of the left globe was performed. Histopathology revealed acute necrotizing keratitis and endophthalmitis. Vitreous analysis showed numerous gram-negative bacilli and a positive culture of Morganella morganii. The patient continued to be managed with frequent lubrications and punctual plugs in the fellow eye during the follow-up period. CONCLUSION: We describe the first case of endophthalmitis developing secondary to PNP-induced corneal melting and perforation. Anticipating unusual infectious sequelae in the setting of PNP might be warranted to actively detect and successfully manage dry eye disease before devastating complications develop.

Variability of ophthalmology residents' perception toward different major training programs in Saudi Arabia.

PURPOSE: The constant demand for ophthalmologists has nationally resulted in creating more programs in different regions of the kingdom. We have previously reported the overall residents' satisfaction with the current local ophthalmology curriculum and the competency of the ophthalmic training (clinical and surgical) in our local programs in Saudi Arabia compared to international standards. In this study, we aim at comparing the major local training programs and analyze the differences among them aiming at improving our training. METHODS: This is a cross-sectional study using a questionnaire that was completed by residents and graduates of the local ophthalmology programs in Riyadh, Eastern and Western regions. A closed-ended questionnaire was validated and circulated online and a hard copy was distributed to residents and recently graduated ophthalmologists (2009-2015). Data were categorized by demographic variables, and basic statistics were done. The study has been approved by the Institutional Review Board (IRB) and Human Ethics Committee (HEC) of King Saud University. RESULTS: Of the 200 individuals surveyed, 175 (87.5%) completed their responses. The average age was 29.6 years (range: 24-39) with 67.5% males and 32.5% females. The overall satisfaction among senior residents and graduates showed a statistically significant higher result among graduates in Riyadh area (P=<0.001). Satisfaction of senior residents with the program director's support was higher in the Eastern region (P=<0.001). Clinic-based training was generally satisfactory. Refractive surgery was reported to be significantly insufficient in 70.6% (P=0.003). Most of the graduates in Riyadh area achieved the surgical requirements for training compared to other regions. CONCLUSION: Saudi postgraduate ophthalmology training programs show a variable level of satisfaction among senior residents and graduates. Better surgical exposure has been observed in Riyadh region, however reassessment of the current curriculum and the parameters for training are needed to fulfill the requirements with special attention to the surgical training in all programs.

Incidence, Risk Factors and Surgical Outcomes of Cataract among Patients with Vogt-Koyanagi-Harada Disease.

Purpose: To investigate risk factors and surgical outcomes of cataract in Vogt-Koyanagi-Harada (VKH) disease.Methods: Review of 187 patients (374 eyes).Results: At presentation, cataract was diagnosed in 56 (14.9%) eyes all had chronic recurrent VKH. During follow-up, cataract developed in additional 51 (13.6%) eyes. Fifteen (13.6%) of these had initial-onset acute VKH with anterior segment (AS) inflammation and 36 (19.4%) had chronic recurrent VKH. No patient with initial-onset acute VKH without AS inflammation developed cataract. Risk factors for cataract development during follow-up included female gender, keratic precipitates, anterior chamber reaction ≥2+, chronic recurrent VKH, posterior synechiae, iris nodules, glaucoma, glaucoma surgery, choroidal neovascular membrane, "sunset glow fundus" and chorioretinal atrophy. Thirty-two eyes underwent cataract extraction. Fourteen (43.8%) eyes achieved ≥20/40. Posterior segment complications of chronic recurrent VKH accounted for <20/40 outcome.Conclusions: Poor outcome after surgery is secondary to posterior segment complications of chronic recurrent VKH.

Intraocular T-cell lymphoma metastasizing from a primary adrenal T-cell lymphoma: Case report.

INTRODUCTION: Most intraocular T-cell lymphomas arise from metastatic source. We are reporting a rare case of intraocular T-cell lymphoma masquerading as pseudo-hypopyon and vitritis. The eye involvement proved to represent a metastatic spread from a co-existing adrenal T-cell lymphoma, which was discovered after the initial ophthalmic presentation. PRESENTATION OF CASE: Our patient was a 71-year-old Saudi man, who was admitted for workup of anemia and weight loss. He also noticed a gradual, painless decline in his vision of both eyes, for which he was referred to the ophthalmology unit. Ocular examination revealed left eye 3 mm pinkish hypopyon. A diagnosis of T-cell lymphoma was made based on careful microscopic examination of the left aqueous fluid, immunohistochemical (IHC) and Flow cytometry analysis. Computerized tomography showed a large invasive left adrenal mass, which has proven to be a primary adrenal lymphoma with multiple metastasis including the intraocular involvement. DISCUSSION: Primary intraocular lymphoma is the most common lymphoma in the eye. Intraocular T-cell lymphoma is rare and is mostly metastatic. On the other hand, primary adrenal lymphoma (especially T-cell lymphoma) is also rare. There are only 5 cases of primary adrenal lymphoma, two of which, resulted in eye metastasis similar to our case. Primary adrenal lymphoma is known to be aggressive. Our patient eventually passed away. CONCLUSION: This report stresses the importance of referring patients with systemic lymphoma to an ophthalmologist to be evaluated for ocular involvement. Even though intraocular metastatic adrenal T cell lymphoma is rare, high clinical suspicion in patients who are presenting with pinkish hypopyon in the presence of other constitutional symptoms is essential.

Attitude, beliefs and awareness towards corneal donation in Saudi Arabia.

PURPOSE: Corneal donation has not received adequate attention in Saudi Arabia, and donors are lacking. This study explores the underlying knowledge of, attitude regarding, and practice of corneal donation in Saudi Arabia, which will possibly help in designing healthcare policies and creating a national eye bank. METHODS: This observational cross-sectional study used a self-administered questionnaire and was administered to the residents of Saudi Arabia from August to December 2017. We surveyed 1292 random subjects who agreed to fill out the self-administered questionnaire. The sample included Saudi and non-Saudi residents across adult age groups from medical and non-medical professions. RESULTS: Of the 1292 respondents, only 4.3% believed that they had sufficient knowledge about corneal donation; 66.3% of the sample had not decided whether to donate their corneas after death; 40.2% stated that they would be more willing to donate if they had sufficient knowledge about corneal donation; and 46.1% of the population did not know where to apply to donate their corneas. Those who believed that they had sufficient information about corneal donation were significantly more likely to donate (p < 0.001) than those who believed they did not have enough information. CONCLUSION: Increased awareness about corneal donation is required, as a higher level of awareness was associated with a higher willingness to donate corneas. Establishing healthcare policies and creating community campaigns is necessary to increase corneal donation awareness and willingness.

Assessment of Ophthalmology Residency Programs in Saudi Arabia: A Trainee-Based Survey.

PURPOSE: To assess the satisfaction and competency of Saudi ophthalmology residents and compare their performance against International Council of Ophthalmology (ICO) standards. METHODS: A cross-sectional web-based survey of senior ophthalmology residents (postgraduate years [PGY] 3-4) and recent graduates (from 2010 to 2015) assessed various aspects of training. The questionnaire was sent to the participants and was divided into 3 main domains: demographics, training program evaluation, and preparedness for board exams and clinical practice. RESULTS: Out of the 145 invitees, 120 (82.8%) responded. Fifty percent of respondents reported an overall satisfaction with the program. Adequate clinical exposure was reported in most subspecialties except refraction and low vision rehabilitation with inadequate exposure reported by 55.8% and 95.8%, respectively. Surgical exposure was reported as adequate for phacoemulsification (58.3%) and strabismus surgery (68.3%) only. Eighty-nine percent of respondents reported performing less than 80 cases of phacoemulsification. Of the respondents who had graduated, most (89.7%) passed the final board exam at the first attempt. There were 73.5% of respondents who reported that residency training prepared them well for the board exam. Ongoing clinical and call duties were reported as having a negative impact on exam performance. CONCLUSIONS: Saudi ophthalmology residents demonstrate a high level of clinical competency. However, additional efforts should aim at improving surgical training to increase the level of satisfaction among residents and improve the quality of training to meet international standards.

Transition to Ophthalmology Residency Program and the Role of Basic Science Course.

BACKGROUND: Residency training is a difficult and a highly stressful task, especially at the beginning of the training. The aim of this study is to assess the roles of the Basic Science Course (BSC) and independent preparation on the transition to ophthalmology residency in Saudi Arabia. METHODOLOGY: A cross-sectional study was conducted among ophthalmology program residents. The questionnaire was administered to 100 residents. Responses were analyzed for association using univariate analysis. RESULTS: Nearly 88% of residents were satisfied with their knowledge exposure during the BSC, while 67% thought that the majority of the BSC was dedicated to theoretical lectures. Surgical exposure was limited to attending surgeries for 38% of residents before joining residency programs, and 91% thought that there was little time dedicated for hands-on surgical skills training during the BSC, while only 11% thought that their surgical exposure was beneficial. Almost half of the beginning residents were accompanied by senior colleagues during their initial calls. More than 50% of residents felt that their transition to ophthalmology residency was more stressful than the transition to internship. CONCLUSION: The knowledge exposure from the BSC was helpful to facilitate the transition to ophthalmology residency program, especially for the ones who prepared well before. Improvement in surgical skills training should be aimed to further facilitate transition to ophthalmology residency program.

Predictors of performance in an ophthalmology residency program.

OBJECTIVE: To assess the value of current selection criteria and additional factors as predictors of performance in an ophthalmology residency training program. DESIGN: A retrospective study. PARTICIPANTS: Data were collected from the files of 166 residents who were collectively trained in an ophthalmology residency program from 2000 to 2013. METHODS: The program's selection criteria included medical school grade point average (GPA), Saudi licensing examination (SLE) score, multiple-choice question ophthalmology selection (MCQ) examination score, and interview mark. Indicators of performance included average scores in the promotion examination for 4 years of training (average R), King Saud University fellowship examination (KSU) score, and Saudi Board in Ophthalmology examination (SBO) score. An average of KSU and SBO scores was also used as a performance indicator. Times of program completion and average performance score across all years in the residency program were used as second-level indicators of performance. RESULTS: There were strong correlations between the MCQ examination score and each training performance indicator (average R, KSU score, SBO score, and average of KSU and SBO scores; p = 0.002, 0.008, 0.05, and 0.002, respectively). The interview mark correlated well with average R (p = 0.001) but not with other indicators. The MCQ examination score and the interview mark were the only predictors of second-level indicators of performance (p = 0.009 and 0.029, respectively). CONCLUSIONS: The MCQ examination score and interview mark were the 2 best predictors of performance as an ophthalmology resident. GPA and SLE score were poor predictors of performance.

Corneal Endothelium in Patients with Anterior Uveitis.

PURPOSE: To investigate a possible effect of intraocular inflammation on corneal endothelium by describing corneal endothelial cell density (ECD) and morphologic variables in eyes with anterior uveitis, and to investigate factors that may influence these findings. DESIGN: Cross-sectional, observational study. Observers were not masked. PARTICIPANTS: Volunteers with histories of unilateral or bilateral anterior segment inflammation (anterior, intermediate, or panuveitis); included were 52 patients (84 eyes with uveitis). METHODS: Endothelial cell density and morphologic variables of both eyes of all study participants were determined by specular microscopy; central corneal thickness was determined by ultrasound pachymetry. MAIN OUTCOME MEASURES: Central corneal ECD, coefficient of variability, percentage hexagonality, and central corneal thickness. RESULTS: Central ECD was lower among eyes that had undergone cataract or glaucoma surgery or both (n = 28; P = 0.0004). After exclusion of eyes with surgery, variables for eyes with uveitis (n = 56) were compared with 2 historical populations of normal, age-matched controls and with contralateral eyes in individuals with unilateral uveitis. Central ECD was lower in eyes with uveitis than in control eyes for all age groups (P ≤ 0.01 for four of six 10-year age intervals compared with the primary control group). Among patients with unilateral uveitis who had not undergone surgery in either eye (n = 12), central ECD was lower in eyes with uveitis (2324 cells/mm(2) [range, 1543-3289 cells/mm(2)]) than in contralateral eyes (2812.5 cells/mm(2) [range, 1887-3546 cells/mm(2)]; P = 0.0005), and percentage hexagonality was lower in eyes with uveitis (54% [range, 33%-66%]) than in contralateral eyes (58.5% [range, 52%-82%]; P = 0.004). There was no significant difference in central corneal thickness between eyes with and without uveitis (P = 0.27). No eyes had clinically apparent central corneal edema. Relationships remained unchanged after exclusion of eyes with herpetic anterior uveitis. Host and disease-related characteristics were evaluated as risk factors for variations in outcome measures. Central ECD was correlated to the duration of active uveitis (r = -0.41; P < 0.0001), maximum intraocular pressure during the course of disease (r = -0.40; P = 0.0002), and maximum laser flare photometry value (r = -0.26; P = 0.020). CONCLUSIONS: Observed relationships suggest that anterior segment inflammation adversely affects the corneal endothelium. Longitudinal studies are warranted to determine whether long-standing anterior uveitis increases risk of endothelial dysfunction, especially in the setting of intraocular surgery.

Successful cataract surgery in a patient with refractory Wegener's granulomatosis effectively treated with rituximab: A case report.

Wegener's granulomatosis is a granulomatous disorder associated with systemic necrotizing vasculitis. Eye involvement occurs in approximately 50% of Wegener's granulomatosis patients and is an important cause of morbidity. Conventional treatment-related morbidity and failure have led to studies of alternative treatment modalities. In this case of a 35-year-old man with severe Wegener's granulomatosis, conventional therapy failed to induce remission. Despite the standard immunosuppressive therapy, progression of the disease was observed, mainly with ocular manifestations and renal impairment. Rituximab was given intravenously and led to remission of both systemic and ocular manifestations of the disease. After 1 year of disease quiescence, he was admitted one week after his third regularly-scheduled rituximab treatment and was started on intravenous methylprednisolone, 500 mg/day for 3 days, before cataract surgery. Subsequently, the patient underwent phacoemulsification cataract surgery in his left eye. Six months later, in the same manner he underwent uneventful phacoemulsification cataract surgery in the right eye with a favorable outcome in both eyes. CONCLUSION: In this patient, rituximab was a well-tolerated and effective remission induction agent for severe refractory Wegener's granulomatosis and led to successful cataract surgery.

Clinical features and visual outcomes of scleritis patients presented to tertiary care eye centers in Saudi Arabia.

AIM: To describe the clinical features, systemic associations, treatment and visual outcomes in Saudi patients with scleritis. METHODS: A retrospective chart review was performed for patients with scleritis presenting to two tertiary care eye hospitals in Riyadh, Saudi Arabia, from 2001 to 2011. Data were collected on the clinical features of scleritis, subtypes of scleritis, associated systemic disease, history of previous ocular surgery and medical therapy, including the use of immunosuppressants. Treatment outcomes were evaluated based on best-corrected visual acuity (BCVA) and response to treatment. RESULTS: Of the 52 patients included in the study, non-necrotizing anterior scleritis was the most common type of scleritis in 22 patients (42.3%), followed by posterior scleritis in 14 patients (26.9%). The majority of cases, 31 patients (59.6%), were idiopathic in nature. Systemic associations were present in 12 patients (23.1%). Infectious scleritis was confirmed in 6 patients (11.5%): 3 with bacterial scleritis after pterygium excision, 2 patients with scleritis related to tuberculosis and 1 patient with scleritis resulting from herpes simplex infection. For the various subtypes of scleritis, BCVA values after treatment and time to remission significantly differed (P<0.05, all cases). Systemic immunosuppressive therapies in addition to steroids were administered to 46.2% of all patients. The T-sign was present on B-scan ultrasonography in 9 (64.3%) of the 14 posterior scleritis patients. CONCLUSION: Non-necrotizing anterior scleritis was the most common subtype of scleritis. Final visual outcome and time to remission differed among the various scleritis subtypes.

Efficacy of punctal occlusion in management of dry eyes after laser in situ keratomileusis for myopia.

PURPOSE: To evaluate the effect of punctal plug use in preventing dry eye after laser in situ keratomileusis (LASIK). MATERIALS AND METHODS: A randomized clinical trial at a tertiary eye care center, Riyadh, Saudi Arabia. Participants underwent LASIK for myopia in both eyes and a lower punctal occlusion in one eye only while the other eye served as control. Both eyes received the same postoperative medications except for lubricant duration (subject eye: four times per day for one week; control eye: four times per day for 6 months). Participants were evaluated at 1 week, 2, and 6 months after surgery for signs and symptoms of dry eye. The main outcome measures were visual acuity; ocular surface parameters; and Ocular Surface Disease Index questionnaire. RESULTS: Seventy-eight eyes of 39 patients were included in this study. The Ocular Surface Disease Index scores of eyes with punctal plugs were better at all follow-up visits, and the differences between both eyes were statistically significant (1 week, p < 0.0001; 2 months, p < 0.0001; 6 months, p = 0.008). At the final follow-up visit, the percentage of normal eyes was higher in eyes with punctal plugs for all ocular surface parameters (Schirmer 1 test, 94.9%; tear breakup time, 77.8%; punctate epithelial keratitis score, 71.8%) compared to eyes without occlusion (Schirmer 1 test, 92.3%; tear breakup time, 58.3%; punctate epithelial keratitis score, 53.8%); however, such differences were not statistically significant. CONCLUSION: Punctal plug insertion after LASIK surgeries may minimize the need for frequent lubricant application and hence improve patient satisfaction.

Ocular manifestations of xeroderma pigmentosum at a tertiary eye care center in Saudi Arabia.

PURPOSE: To study the clinical profile of Saudi cases of xeroderma pigmentosum (XP). DESIGN: This is a single-center, retrospective, consecutive case series of all cases of XP seen at King Khaled Eye Specialist Hospital from January 1, 1986, to December 31, 2006. The main outcome measures were clinical features, visual outcome, and histopathologic findings. RESULTS: Of 33 patients initially included in this study, 6 were excluded from the final analysis because of either unconfirmed diagnosis of XP or insufficient follow up. The final analysis included 27 patients (14 female patients, 13 male patients). A history of consanguinity was present in the parents of one third of our patients. The age at onset of ocular complications ranged from 5 to 67 years (median age, 19 years). The number of patients with no light perception (NLP) increased from 1 patient (3.7%) at the initial visit to 5 patients (18.5%) at the last visit. In 13 of 27 patients (48.1%), conjunctival tumors were observed; 10 tumors were confirmed histopathologically to be squamous cell carcinomas. Basal cell carcinoma (BCC) was the most common histopathologic diagnosis of eyelid tumors and was noted in 4 patients (14.8%). Furthermore, 10 patients (37.0%) had a history of skin malignancy, and 5 patients (18.1%) had neurologic abnormalities. CONCLUSION: Patients with XP who presented to a tertiary eye care center in Saudi Arabia had a high percentage of consanguinity in parents and late onset of ocular complications. Additionally, XP behaved aggressively in both malignancy profile and visual outcome.