Retinal Pigment Epithelial Adenoma: Initial Treatment Outcomes following Episcleral Brachytherapy.

Introduction: We aim to explore the safety and efficacy of episcleral brachytherapy as a primary management option for eyes with retinal pigment epithelial (RPE) adenoma. Methods: Retrospective chart review of the demographic, clinical, ancillary, and postoperative outcome data of patients with RPE adenoma in 2 tertiary referral centers. Tumor regression, final visual acuity, and complications were assessed. Results: Five patients (3 females and 2 males) were included. Four of the 5 eyes had peripheral and mid-peripheral lesions, while one tumor was juxtapapillary. Three eyes were treated with ruthenium-106 (100 Gray), and 2 received iodine-125 episcleral plaques (85 Gray). All eyes showed clinical and imaging-based evidence of regression. Four eyes had stable or improved visual acuity, while 1 eye exhibited one line loss of visual acuity due to radiation retinopathy. Local recurrence was not observed in any eye over a median follow-up of 24 (range 6-112) months. Conclusions: Episcleral brachytherapy is an effective management option for select cases of RPE adenoma that is capable of achieving tumor regression while maintaining favorable visual acuity. The initial safety profile of brachytherapy is good without significant vision-compromising complications.

Outcome of intraocular lens exchange for the management of myopic shift in pseudophakic children.

PURPOSE: To evaluate the visual outcome of intraocular lens (IOL) exchange for the management of myopic shift in pseudophakic children. METHODS: The medical records of children who underwent IOL exchange for myopic shift were examined. The preoperative data, operative details and the postoperative outcome were analyzed. RESULTS: Twenty-one eyes (16 patients) were identified. Mean age at cataract extraction was 20 ± 26 months (range, 2-84 months). Twelve patients (6 unilateral, 6 bilateral) had primary IOL implantation. Mean age at IOL exchange was 7.3 ± 3.2 years. Mean spherical equivalent (SE) at IOL exchange was -14 ± 5 D (range, -7 to -21 D): Mean SE at IOL exchange was -13.64 ± 4.99 D, -12 ± 1.53 D, and -15.5 ± 4.7 D in unilaterally pseudophakic cases (8 patients), in the eye that underwent unilateral IOL exchange (3 patients) in bilaterally pseudophakic cases, and in bilateral IOL exchange cases (5 patients), respectively. Mean axial length at IOL exchange was 24 ± 1.3 mm (range, 23 to 27 mm). Following IOL exchange, mean SE was reduced to -2 ± 1.8 D (range, -4 to +2.5 D). An average of three logMAR line improvement in the best-corrected visual acuity was observed in 12/16 eyes of patients for whom pre- and post-exchange visual acuity were available, while visual acuity remained unchanged in 4 eyes. Mean logMAR visual acuity improvement was 0.35 and 0.49 in unilateral and bilateral pseudophakic cases, respectively. CONCLUSIONS: IOL exchange is a safe procedure that should be considered to improve visual rehabilitation in pseudophakic patients with myopic shift.

Overcorrection after vertical muscle transposition with augmentation sutures in sixth nerve palsy.

PURPOSE: To report a series of cases, who developed consecutive exodeviation after vertical muscle transposition (VRT) performed for sixth nerve palsy, describe their management and analyse their outcome. DESIGN: Retrospective case series. METHODS: This is an institutional study on patients who developed consecutive exotropia following VRT for sixth nerve palsy in two different centres. The age, gender, cause, and time to surgery were reviewed. Ductions, versions and angles of misalignment were analysed. In those who developed an exotropia >10 PD after surgery, a second surgery was performed. The time to the second surgery, intra-operative findings, surgical procedure and outcome were studied. RESULTS: A total of 164 cases of VRT for sixth nerve palsy were identified. Nine patients developed consecutive exotropia >10 PD (5.5%). There were no significant differences in the characteristics of those who developed overcorrection compared to those who did not. Five patients had full-tendon muscle transposition, three patients had Hummelsheim procedure and one patient had Jensen procedure. The average angle of consecutive exotropia was 26 ± 9 Δ (range 10-40 Δ). After the second surgery, angle of exotropia decreased to 21 ± 15 PD. Seven patients still had residual exotropia ≥10Δ and the exotropia was corrected in the remaining two patients. The time to second surgery in those two patients was much shorter than the other seven patients. CONCLUSIONS: Patients who undergo VRT should be followed up in the early post-operative period and revisiting the transposition should be done immediately in case of consecutive exotropia to avoid permanent overcorrection.

Predictive Value of Intraocular Lens Power Calculation Formulae in Children.

PURPOSE: To compare the accuracy of IOL power calculation formulae in a large cohort of children who underwent IOL implantation. SETTING: Cairo University Children Hospital. DESIGN: Retrospective, case series. METHODS: A retrospective chart review of all children <14 years, who underwent primary or secondary IOL implantation in Cairo University Children Hospital from January 2016 to December 2019, was performed. Absolute prediction error (APE) was calculated for SRKII, SRK/T, Holladay I and Hoffer-Q formulae using the patients' AL, keratometric (K) readings, implanted IOL power and refraction done two months postoperatively. RESULTS: The study included 308 eyes of 255 patients with a mean age of 4.74 ± 3.19 years at the time of surgery. The mean K-reading was 43.42 ± 3.57 diopters (D) and mean AL was 22.01 ± 1.93 mm. The percentage of eyes with APE within 0.5D was 27.7% (85 eyes), 32.2% (99 eyes), 30.6% (94 eyes) and 25.4% (78 eyes) with SRK II, SRK/T, Holladay I and Hoffer-Q formulae, respectively. APE was significantly lower with the SRK/T formula (P≤0.004) and significantly higher with the Hoffer-Q formula (P≤ 0.002). There was a negative correlation between the age of the patient and the APE of the SRK II formula (P=0.02). Moreover, the SRK/T, Holladay and Hoffer-Q formulae APEs were affected by the average k-readings (P=0.019, 0.005 and 0.035) respectively. CONCLUSION: The SRK/T and Holladay I formulae were the most predictable formulae in IOL power calculation in pediatric eyes.

Exotropic heavy eye syndrome in unilateral high axial myopia.

PURPOSE: To describe a pattern of combined exotropia and hypotropia in patients with unilateral high myopia and to suggest a surgical approach for their management. METHODS: In this observational study of 13 patients presenting with unilateral combined exotropia and hypotropia with high axial myopia in the deviating amblyopic eye, cycloplegic refraction, visual acuity, ocular motility, and orbital imaging findings were evaluated. For patients who had undergone surgery, the intraoperative findings and their surgical outcome were also analyzed. RESULTS: Median age at presentation was 27 ± 14.6 years. In the deviated eyes, mean spherical equivalent was -13.6 ± 9 D; mean axial length, 28.3 ± 1.7 mm. The mean preoperative horizontal and vertical angles of deviation in primary gaze were 46.5 ± 12.1Δ (range, 25-60) and 21.1 ± 6.5Δ (range, 15-35), respectively. All patients had a V pattern, with limitation of elevation in abduction. Magnetic resonance imaging revealed no evident displacement of the lateral rectus muscles in all cases. Six patients (46%) had surgical intervention. In 5 cases, the lateral rectus was displaced inferiorly by a mean of 2.5 mm (range, 2-4 mm) and was recessed and transposed 8 mm upward. The muscle was then fixated to the sclera with a nonabsorbable polyester suture 2-4 mm behind its new insertion. Successful surgical outcome was achieved in 5 cases (83%). CONCLUSIONS: Combined exotropia and hypotropia associated with high myopia shows an overlap in the clinical presentation of the heavy eye syndrome. Although not evident radiologically, downward displacement of lateral rectus muscle was documented intraoperatively.

Factors associated with early and late failure after goniotomy for primary pediatric glaucoma.

PURPOSE: To analyze the risk factors associated with early and late failure after goniotomy for primary pediatric glaucoma. METHODS: A retrospective study was done on infants who underwent goniotomy as the initial surgical procedure for primary pediatric glaucoma, and had a follow-up period ⩾48 months after surgery. Early and late failures were defined as intraocular pressure ⩾18 mmHg or signs of glaucoma progression before and after the end of first year, respectively. RESULTS: A total of 81 eyes of 47 children were included. The mean age at the time of surgery was 6.1 ± 6.7 months, 34 children (72.3%) were bilateral. The mean follow-up was 5.9 ± 2.8 years. Of the included eyes, 41 eyes (50.6%) showed success, 25 eyes (30.9%) showed an early failure, and 15 eyes (18.5%) showed a late failure. The mean survival time was 43 months. However, only surgery before the end of the first month and positive consanguinity of the parents (P < 0.01 for both) were independent risk factors for early and late failure of goniotomy for primary pediatric glaucoma. Patients with late failure showed a statistically significant lower preoperative intraocular pressure (P = 0.02). A larger preoperative corneal diameter and a male gender were associated with higher but statistically insignificant failure rates. There were no differences in the early or late failure rates between unilateral and bilateral cases. CONCLUSION: A positive consanguinity of the parents and surgery before the end of the first month are the major predictors of failure of goniotomy.

Worldwide inequality in access to full text scientific articles: the example of ophthalmology.

BACKGROUND: The problem of access to medical information, particularly in low-income countries, has been under discussion for many years. Although a number of developments have occurred in the last decade (e.g., the open access (OA) movement and the website Sci-Hub), everyone agrees that these difficulties still persist very widely, mainly due to the fact that paywalls still limit access to approximately 75% of scholarly documents. In this study, we compare the accessibility of recent full text articles in the field of ophthalmology in 27 established institutions located worldwide. METHODS: A total of 200 references from articles were retrieved using the PubMed database. Each article was individually checked for OA. Full texts of non-OA (i.e., "paywalled articles") were examined to determine whether they were available using institutional and Hinari access in each institution studied, using "alternative ways" (i.e., PubMed Central, ResearchGate, Google Scholar, and Online Reprint Request), and using the website Sci-Hub. RESULTS: The number of full texts of "paywalled articles" available using institutional and Hinari access showed strong heterogeneity, scattered between 0% full texts to 94.8% (mean = 46.8%; SD = 31.5; median = 51.3%). We found that complementary use of "alternative ways" and Sci-Hub leads to 95.5% of full text "paywalled articles," and also divides by 14 the average extra costs needed to obtain all full texts on publishers' websites using pay-per-view. CONCLUSIONS: The scant number of available full text "paywalled articles" in most institutions studied encourages researchers in the field of ophthalmology to use Sci-Hub to search for scientific information. The scientific community and decision-makers must unite and strengthen their efforts to find solutions to improve access to scientific literature worldwide and avoid an implosion of the scientific publishing model. This study is not an endorsement for using Sci-Hub. The authors, their institutions, and publishers accept no responsibility on behalf of readers.

Outcomes and Complications Rate of Resident versus Attending Performed Eye Muscle Surgeries.

Purpose: to compare the type, complications rate, and success rate of eye muscle surgeries performed by residents to those performed by attending consultants. Methods: A retrospective review was done on the charts of all children who underwent an eye muscle surgery in Cairo University Hospital during the period from January 2015 to December 2017. Preoperative data including age, sex, and type of deviation were tabulated. Details of the operative procedure including the surgeon, the type of eye muscle surgery, the number of muscles operated upon, perioperative complications, and the final ocular alignment at the end of the third month after surgery were recorded. Results: A total of 319 patients were included; 143 patients (315 muscles) in the supervised resident group and 176 patients (387 muscles) in the attending group. More vertical and oblique muscles surgeries were done by the attending consultants than by residents. Surgical success after three months was higher in the attending group (n = 126, 72%) than the resident group (n = 91, 64%). However, the difference was not statistically significant (P = .129). The perioperative complications rate was significantly higher (P = .004) in the resident group (14%) than the attending group (6%). Accidental scleral perforation was the most commonly encountered complication in the resident group (n = 6, 1.9%) followed by extruded/exposed Tenon (n = 5, 1.6%), and muscle slippage (n = 4, 1.3%). Conclusions: Success rate is similar in eye muscle surgeries performed by residents and attending consultants. However, perioperative complications are still more common among residents.

Steroid-induced ocular hypertension in the pediatric age group.

PURPOSE: Comparing the effects of topical Rimexolone versus Dexamethasone and Rimexolone versus Fluorometholone on the intraocular pressure in children <13 years. METHODS: A total of 40 patients (80 eyes) undergoing bilateral recession strabismus surgery were divided into two groups. Group A included 20 children (40 eyes); for each, one eye was randomized to receive 1% Rimexolone and the fellow eye received 0.1% Dexamethasone. Group B included 20 children (40 eyes); for each, one eye was randomized to receive 1% Rimexolone and the fellow eye received 0.1% Fluorometholone. Patients received eye drops for two consecutive weeks. Preoperative and postoperative intraocular pressure values for weeks 1, 2, 3, 4, and 6 were measured. The ocular-hypertensive response of all patients was categorized as either high, intermediate or low (Armaly-Becker Classification). RESULTS: After a 2-week treatment for both groups, peak and maximal intraocular pressure changes were reached. Changes were significantly higher in the Dexamethasone-treated eyes than in the Rimexolone- and Fluorometholone-treated eyes, which had a comparable change. (Week 2 intraocular pressure Group A: 14.15 ± 3.23 mmHg vs 17.95 ± 4.27 mmHg; Group B: 15.1 ± 2.27 mmHg vs 15.2 ± 2.73 mmHg). In both groups, the increase was statistically significant compared to the baseline intraocular pressure (preoperative intraocular pressure Group A: 13.2 ± 3.53 mmHg vs 13.1 ± 3.43 mmHg; Group B: 12.55 ± 2.98 mmHg vs 12.15 ± 3.31 mmHg). Intraocular pressure returned to near preoperative values over the following four consecutive weeks (Week 6 intraocular pressure Group A: 12.25 ± 2.67 mmHg vs 12.55 ± 2.95 mmHg; Group B: 12.15 ± 2.8 mmHg vs 12.00 ± 2.75 mmHg). None of the patients were high responders. CONCLUSION: Dexamethasone caused a higher elevation in intraocular pressure than Rimexolone and Fluorometholone in children. The ocular-hypertensive response was transient after the 2-week course.

Iris reconstruction using artificial iris prosthesis for management of aniridia.

PURPOSE: To discuss the limitations and benefits of the BrightOcular prosthetic artificial iris device in management of aniridia associated with aphakia or cataract. METHODS: This is a retrospective study including 5 eyes of 4 patients who underwent implantation of the BrightOcular iris prosthesis (Stellar Devices) for total or partial aniridia. The cases included 2 eyes of 1 patient with congenital aniridia associated with congenital cataract and 3 eyes with traumatic aniridia: 1 with subluxated cataractous lens and 2 with aphakia. In all cases, the iris prosthesis was implanted after a 3-piece acrylic intraocular lens was implanted. We evaluated the clinical course with a minimum follow-up period of 6 months, the intraoperative and postoperative complications, and the cosmetic satisfaction of patients. RESULTS: All patients had improved uncorrected distance visual acuity and best-corrected distance visual acuity. All patients had a transient corneal edema that resolved within the first postoperative week. Only the patient with congenital aniridia had a permanent increase in intraocular pressure and developed a band keratopathy throughout a 2-year follow-up period. The prosthesis was well-centered in all eyes except for one case that required scleral suture fixation after 3 months. All patients had a satisfactory cosmetic appearance. CONCLUSIONS: BrightOcular iris prosthesis is a safe and useful tool to correct aniridia associated with pseudophakia or aphakia. Being foldable, it is easy to be implanted through a small incision and placed in the ciliary sulcus without sutures when properly sized. Cosmetic results are satisfactory. Sizing methods should be improved.