Multi-modal imaging for the detection of early keratoconus: a narrative review.

Keratoconus is a common progressive corneal disorder that can be associated with significant ocular morbidity. Various corneal imaging techniques have been used for the diagnosis of established cases. However, in the early stages of the disease, which include subclinical keratoconus and forme fruste keratoconus, detection of such cases can be challenging. The importance of detecting such cases is very important because early intervention can halt disease progression, improve visual outcomes and prevent postrefractive surgery ectasia associated with performing corneal refractive procedures in such patients. This narrative review aimed to examine several established and evolving imaging techniques for the detection of early cases of keratoconus. The utilization of combinations of these techniques may further increase their diagnostic ability.

The Effect of Visual Impairment and Its Severity on Vision-Related and Health-Related Quality of Life in Jordan: A Comparative Cross-Sectional Study.

Purpose: To assess the effect of visual impairment (VI), its severity, and ocular diseases on vision-related and health-related quality of life (QoL) in Jordan. Patients and Methods: A comparative, cross-sectional, hospital-based study was conducted among a group of 278 patients with VI aged ≥ 18 years, and age and sex-matched control group of 278 individuals with no VI. An interviewer administered the National Eye Institute Visual Function Questionnaire (NEI VFQ-25) and the Medical Outcomes Study 12-Item Short Form Health Survey (SF-12) to all participants. Results: All the mean VFQ-25 subscales scores, physical component scale (PCS) and the mental component scale (MCS) of the SF-12 were significantly lower in patients with VI compared to controls with no VI. The VFQ-25 subscales (except general health and ocular pain), PCS, and MCS scores significantly decreased with more severity of VI. In the adjusted multivariate analysis, lower level of education (p=0.013), male sex (p=0.016), and the presence of cerebrovascular disease (p=0.019) were significantly associated with lower VFQ-25 composite scores in visually impaired patients compared to controls. Ocular disease duration of >5 years and progressive VI were significantly associated with lower VFQ-25 composite scores (p= 0.026 and p<0.001) respectively, in patients with VI. Glaucoma had a significantly larger reduction in mean scores of all the VFQ-25 subscales, and the PCS of the SF-12 compared to all other ocular diseases. Conclusion: Both VI and increasing severity of impairment were associated with reduced vision-related and health-related quality of life in adult Jordanians. Glaucoma patients and less educated people were particularly affected. Routine assessment of QoL in visually impaired patients and improving referral protocols to vision rehabilitation services is recommended to improve the QoL in those patients.

The Relationship between Pinguecula and Diabetes Mellitus: A Comparative Cross-Sectional Study.

Purpose: To assess the relationship between diabetes mellitus (DM) and the presence of pinguecula and to identify other risk factors associated with pinguecula in patients attending the eye clinic at two tertiary university hospitals in Jordan. Methods: This was a comparative cross-sectional hospital-based study of 241 consecutive patients (122 patients with DM and 119 patients with no diabetes). All patients underwent complete ophthalmic examination, and data were collected regarding age, sex, occupational activity, presence and grade of pinguecula, glycosylated hemoglobin (HbA1c), and presence of diabetic retinopathy. Results: The mean (standard deviation, SD) ages of the DM and non-DM groups were 59.5 (10.8) years and 59.0 (11.6) years (p-value = 0.729), respectively. There was no significant difference in the prevalence of pinguecula between the diabetic and nondiabetic groups (66.4% vs. 66.5%, p = 0.998). Multivariate logistic regression analysis revealed that only outdoor occupational activity (OR = 5.16, 95% CI: 1.98-13.44, p = 0.001) was associated with increased prevalence of pinguecula. DM was not significantly associated with pinguecula (OR = 0.96, 95% confidence interval (CI): 0.55-1.67, p = 0.873). Neither age nor sex were significantly associated with pinguecula (p-value = 0.808, p-value = 0.390), respectively. Conclusion: DM was not significantly associated with the development of pinguecula in this Jordanian population. The prevalence of pinguecula was significantly associated with an outdoor occupational activity.

Normative Data of Macular Thickness Using Spectral Domain Optical Coherence Tomography for Healthy Jordanian Children.

Purpose: To report normative values of macular thickness and volume by spectral-domain optical coherence tomography (SD-OCT) in the eyes of healthy Jordanian children aged 6-16 years and assess the correlation of macular parameters with age, sex, and refractive error. Patients and Methods: This observational study included 144 eyes of 144 healthy children. All children underwent comprehensive ocular examination and cycloplegic refraction. Average macular thickness, macular volume, central subfield thickness (CST), and macular thickness for all the Early Treatment Diabetic Retinopathy Study (ETDRS) quadrants were obtained using Primus SD-OCT (Carl Zeiss Meditec). Results: The study group consisted of 68 boys and 76 girls with a mean age (SD) of 10.8 (3.0) years. The mean (SD) spherical equivalent refraction (SER) was 0.56 (1.73) diopters (range: -4.75 to 4.75). The mean of macular average thickness was 277.2±12.5 µm, and the mean of the central subfield thickness was 246.7±16.8 µm. In multivariate analysis, all macular parameters except the central subfield thickness (CST) correlated positively with the SER. Boys had significantly higher CST than girls (p=0.008). None of the macular parameters were correlated with age. Conclusion: Normative data of macular thickness for healthy Jordanian children were established for sex and age groups using SD-OCT.

Adults with Longstanding Strabismus: Psychosocial and Functional Impacts and Reasons behind Surgery Delay.

Purpose: The aims of the study were to determine the reasons behind surgical correction delay in adult patients with strabismus, reveal motivations for seeking treatment, and study the psychosocial and functional impacts of strabismus on patients using an Arabic version of the Adult Strabismus-20 (AS-20) questionnaire. Methods and Patients. This study included 79 patients aged ≥18 years and had strabismus for at least one year prior to surgical correction and 40 controls without known visual defects. After a comprehensive ophthalmic exam during their preoperative visit, a validated questionnaire was administered to patients to collect sociodemographic data, reasons for surgery delay, and motivations for seeking treatment now. A translated version of the AS-20 questionnaire was then presented to patients and controls. Total AS-20 (and its subscales: psychosocial and function) scores were calculated and analyzed. All relationships between sociodemographic characteristics, the onset of deviation, presence of diplopia, type and size of deviation, and the changes in the scores of AS-20 (and its subscales) were investigated. Results: A total of 79 adult patients with strabismus (cases) and 40 subjects with normal vision (control group) were included in this study. The mean age (SD) was 34.10 (11.5) years for cases (range: 18-61) and 34.20 (11.2) years for controls (range: 18-65) (p=0.964). About half (55.7%, n = 44) of the patients were males compared to (57.5%, n = 23) of the controls. The reasons for strabismus surgery delay reported by the patients were the following: surgery was not offered by an ophthalmologist (35.4%), surgery was offered but declined by the patient due to fear from surgical complications (22.8%), nonaffordability (17.7%), surgery was offered but refused because patients thought they were too old for surgery or patient was not bothered by appearance (15.2%), and patient never sought care (8.9%). The reasons for seeking surgical treatment after this delay were as follows: for cosmetic issues (27.8%), a better understanding of strabismus surgery and its potential complications (20.3%), pressure from family and friends (16.5%), improved economic status (13.9%), relationship/marriage prospects (13.9%), and to improve chances of getting a job (7.6%). When compared to control, patients have significantly lower mean scores of total AS-20 (50.57 vs. 88.01) and its psychosocial (49.59 vs. 87.84) and functional (51.55 vs. 88.19) subscales. AS-20 total score was significantly lower among females and in patients with large deviation size (>25 PD). The psychosocial subscale of AS-20 was significantly lower in females, patients with younger age of onset, and those with large deviation size (>25 PD). Female gender, large deviation size, vertical deviation, and having diplopia correlated significantly with a lower functional score. Conclusion: Strabismus has a profound psychosocial and functional impact on affected individuals, especially females and patients with large deviation sizes. Many adult patients with strabismus tend to delay surgical correction; most of these delays could be avoided by better public education, increased awareness among health care providers, and changing health insurance policies to cover the costs of strabismus surgery.

Time for effective cycloplegia in patients with brown iris.

We aimed to evaluate the time needed for effective cycloplegia after instillation of cyclopentolate 1% in patients with brown irides. A prospective analytical study involving 161 patients (322 eyes) with a mean (SD) age of 9.0 (3.1) years (range: 3-16 years), who attended outpatient eye clinic. All had brown irides, cyclopentolate 1% was instilled two times, 10 minutes apart, spherical equivalent (SE) was calculated using readings taken by Nidek AR-1000 autorefractometer before the first drop and at 15, 30, 45 and 60 minutes after the first drop. The time for effective cycloplegia was determined from the time point at which the 95% confidence interval of the differences between the average spherical equivalent (SE) at each point and its final value at 60 minutes was reached and remained within ±0.25 D. We found that maximum cycloplegia was reached 30 minutes after the instillation of first drop of cyclopentolate 1% in all refractive error categories (emmetropia, hyperopia and myopia) with the exception of high hyperopia subgroup (SE ≥ +6.0D) where at least 45 minutes were needed to achieve cycloplegia. Additionally no clinically significant difference in the minimum time required to achieve maximum cycloplegia was noticed in subjects under 10 years old and those aged 10 years or older with both groups needed at least 30 minutes to achieve maximum cycloplegia after the instillation of first drop of cyclopentolate 1%. In this group of patients with brown irides, most children reached maximum cycloplegia after 30 minutes of instillation of cyclopentolate 1% eye drops.

Perception and experience of academic Jordanian ophthalmologists with E-Learning for undergraduate course during the COVID-19 pandemic.

BACKGROUND: Electronic-learning (e-Learning) is a form of education that utilizes information and communications technology to access online teaching and learning. This study aims to evaluate the e-Learning experience among Jordanian academic ophthalmologists during the coronavirus disease 2019 (COVID-19) pandemic. MATERIAL AND METHODS: A cross-sectional survey was applied by using a questionnaire that was distributed among 23 academic ophthalmologists working at 6 medical schools in Jordan during the lockdown. The questionnaire included questions about the ophthalmologists' experience with e-Learning, advantages and disadvantages of e-Learning, interactions of medical students for the e-Learning and the expectations of e-Learning for the future. RESULTS: A total of 22 out of 23 academic ophthalmologists responded. Flexibility of e-Learning to time and place was a major advantage (95.5%), whereas lack of skills was the main obstacle for e-Learning (77.3%). Nineteen participants (86.4%) were not satisfied with e-Learning as the sole method for undergraduate teaching. To improve the original on-campus two-week ophthalmology course, 12 (54.5%) suggested integrating e-Learning into the curriculum, 3 (13.6%) preferred extending the period of training, and 7 (31.8%) reported that their tight schedule does not allow for more tasks. CONCLUSION: The experience of e-Learning was positive. Most believed that e-Learning would have a prominent role in the future of medical education and proposed blended learning programs.

Awareness, Perceptions, and Attitude Regarding Coronavirus Disease 2019 (COVID-19) Among Ophthalmologists in Jordan: Cross-Sectional Online Survey.

PURPOSE: COVID-19 pandemic is a serious public health concern, and the role of health care workers is essential in preventing spread. The study objective is to investigate awareness, perception, and attitude towards COVID-19 and infection control measures among ophthalmologists in Jordan. METHODS: The design of the study was a cross-sectional survey among Jordanian ophthalmologists. An online survey was sent to 197 ophthalmologists on March 23, 2020. Information on participants' socio-demographic characteristics, knowledge of clinical features of COVID-19, risk assessment and infection control measures for preventing disease transmission, and attitude towards treating patients with COVID-19 were collected. RESULTS: A total of 132 ophthalmologists (mean age 40.5 years) responded, 23 (17.6%) had received training on infection control in ophthalmology. Most ophthalmologists were aware of COVID-19 symptoms and ways to identify patients at risk of having the disease, correctly reported modes of transmission and were aware of measures for preventing COVID-19 transmission in the ophthalmic setup. Social media was the commonest source of information on COVID-19 (75%), and 38.2% were not provided with instructions on infection control plan to reduce transmission of COVID-19. Most ophthalmologists (79.5%) thought that the virus could be detected in tears, and 72.2% thought that red eye as a symptom of COVID-19. CONCLUSION: Ophthalmologists in Jordan were aware of the epidemiology of COVID-19 and related infection preventive measures. Knowledge was lacking regarding ocular aspects of the disease. Training on infection prevention needs to be improved. Access to guidelines from international ophthalmological organizations should be promoted and seeking updated literature from peer-reviewed journals needs to be encouraged.

Retinoblastoma in Jordan, 2003-2013: ocular survival and associated factors.

PURPOSE: To determine ocular survival and factors affecting globe survival in patients diagnosed with retinoblastoma at King Hussein Cancer Center (KHCC). METHODS: A retrospective review of medical records of 71 Jordanian patients (45 males and 26 females) diagnosed with retinoblastoma (114 eyes) between June 2003 and May 2013 was conducted. Patient sociodemographic and relevant characteristics were collected from records. Patients with bilateral retinoblastoma were treated with chemoreduction and focal consolidation. Lens-sparing radiation therapy and enucleation were reserved for eyes that failed chemoreduction combined with focal therapy. In cases of unilateral retinoblastoma, primary enucleation was recommended for eyes with advanced unilateral disease (Reese-Ellsworth classification groups IV and V). Kaplan-Meier survival and Cox regression multilevel analysis were used to analyze the data. RESULTS: Median age at diagnosis was 12 months. The follow-up period ranged from 0.25-160 months (mean 26.9 months). The Kaplan-Meier estimate of globe survival of the 114 eyes was 68.0% at 1 year, 63.3% at 2 years, and 62.1% at 5 years. The mean survival time was 101.6 months (95% confidence interval, CI, 87.6-115.6 months). In multivariable-adjusted analysis, advanced stage of the disease (hazard ratio, HR, 5.1, 95% CI 2.3-11.6), unilateral disease (HR 3.3, 95% CI 1.4-8.1), and delay in diagnosis (HR 2.4, 95% CI 1.1-5.5) were significantly associated with increased hazard of enucleation. CONCLUSION: The overall ocular survival rate for eyes with retinoblastoma was close to regional and international figures. Disease stage, laterality, and delay in diagnosis were significant predictors of enucleation.

Posterior segment causes of reduced visual acuity after phacoemulsification in eyes with cataract and obscured fundus view.

PURPOSE: To determine posterior segment causes of reduced visual acuity after phacoemulsification in eyes with cataract and obscured fundus view. PATIENTS AND METHODS: Retrospective review of medical records of patients with cataract, obscured fundus view, and normal B-scan ultrasonography, undergoing phacoemulsification from May 2005 to March 2012 was conducted. Eyes with fundus pathology, previous trauma, surgery, glaucoma, amblyopia, or uveitic cataract were excluded. Ocular comorbid conditions, preoperative visual acuity (VA), intraoperative and early postoperative complications, and final best corrected visual acuity (BCVA) at 1 month were abstracted from the records. RESULTS: All 201 eyes of 179 patients studied had a preoperative VA of ≤6/60. Preoperative ocular comorbidity was present in 31 eyes (15.5%). Intraoperative complications occurred in 20 eyes (10%). Postoperative complications developed in 34 eyes (17.0%). One month postoperatively, 175 eyes (87.1%) achieved a BCVA of ≥6/12; whereas 26 eyes (12.9%) achieved a BCVA of ≤6/18. The most common posterior segment causes of reduced VA in the 26 eyes were age-related macular disease in ten eyes (38.5%) and diabetic maculopathy in six eyes (23.1%). Similar fundus pathology was seen preoperatively in the fellow fundus in 10 of the 26 eyes (38.5%). CONCLUSION: One month after phacoemulsification in eyes with cataract and obscured fundus view, age-related macular disease and diabetic maculopathy were the most common posterior segment causes of reduced final BCVA. To avoid postsurgical dissatisfaction, patients with obscured fundus view in their preoperative eye should be counseled, especially if posterior segment pathology exists in their fellow eye.

Ruptured globe 20 years after radial and transverse keratotomy.

To report a case of corneal rupture due to blunt trauma occurring 20 years after radial keratotomy (RK) and transverse keratotomy. A 57-year-old woman sustained direct blunt trauma to her right eye. Ocular examination revealed a ruptured globe involving two of the eight RK incisions connected together across the visual axis with iris incarceration in the wound. The transverse keratotomy scars remained intact. The patient underwent primary corneal wound repair and iris repositioning. The postoperative period was uneventful. The patient had a visual acuity of counting fingers at 1 m and is awaiting penetrating keratoplasty. Traumatic rupture of RK incisions can still occur after 20 years. Patients having undergone RK many years before should be warned of a possible life-long risk of traumatic rupture. RK scars appear to be more vulnerable to rupture than astigmatic keratotomy scars.