Outcomes of Phacoemulsification With or Without Kahook Dual Blade Goniotomy for Glaucoma Patients with Cataract.

PRECIS: This meta-analysis examines the comparative efficacy of phacoemulsification with and without Kahook Dual Blade Goniotomy in individuals with glaucoma and cataract, aiming to elucidate optimal surgical approaches for coexisting conditions. PURPOSE: The purpose of this current study is to compare the effect of combining Kahook Dual Blade (KDB) goniotomy with phacoemulsification versus phacoemulsification alone on intraocular pressure (IOP) and medication reduction in patients with glaucoma and cataract. METHODS: We conducted a systematic review and meta-analysis utilizing computer databases, including Embase (OVID), MEDLINE (OVID and PubMed), CINHAL (EBSCO), and the Cochrane Library (Wiley). We included studies examining the IOP-lowering effect of KDB goniotomy combined with phacoemulsification and studies that examined the IOP-lowering effect of phacoemulsification alone in patients with open angle glaucoma or ocular hypertension. The mean reduction of IOP and the reduction in topical glaucoma eye drops after surgery were determined. RESULTS: A total of 26 studies were included reporting on 1659 patients, 684 patients underwent phacoemulsification alone and 975 underwent combined phacoemulsification and KDB goniotomy. A 9.62% IOP reduction from baseline occurred following phacoemulsification as a solo procedure compared to 22.74% following combined KDB goniotomy with phacoemulsification. Similarly, the combination of the procedures caused a significant drop in the mean number of glaucoma eye drops used (mean reduction=1.35, 95% CI [1.08, 1.61]) compared to phacoemulsification alone (mean reduction=0.36, 95% CI [0.06, 0.66]). Funnel plots suggested the absence of publication bias. CONCLUSION: Both phacoemulsification alone or combined with KDB goniotomy result in a significant decrease in post-op IOP and topical glaucoma eye drops. The combination of these two procedures outperforms phacoemulsification alone in terms of both parameters.

Phacoemulsification with and without iStent: A Systematic Review and Meta-Analysis of Comparative Studies.

BACKGROUND: The iStent (Glaukos Corporation; Laguna Hills, CA, USA) is one of the minimally invasive glaucoma devices. It can be inserted at the time of phacoemulsification or as a stand-alone procedure to lower the intraocular pressure (IOP). OBJECTIVE: Our aim was to conduct a systematic review and meta-analysis comparing the effect of iStent insertion at the time of phacoemulsification with phacoemulsification alone in patients with ocular hypertension or open-angle glaucoma. METHODS: We searched EMBASE, MEDLINE (OVID and PubMed), CINAHL, and Cochrane Library for articles published between 2008 and June 2022 (PRISMA 2020 for the checklist). Studies comparing the IOP-lowering effect of iStent with phacoemulsification versus phacoemulsification alone were included. The endpoints were IOP reduction (IOPR) and the mean reduction in the number of glaucoma drops. A quality-effects model was used to compare both surgical groups. RESULTS: Ten studies were included, reporting on 1,453 eyes. Eight hundred fifty three eyes had the combined iStent and phacoemulsification, and 600 eyes underwent phacoemulsification alone. IOPR was higher in the combined surgery at of 4.7 ± 2 mm Hg compared to 2.8 ± 1.9 mm Hg in phacoemulsification alone. A greater decrease in postoperative eye drops was noted in the combined group having a decrease of 1.2 ± 0.3 eye drops versus of 0.6 ± 0.6 drops in isolated phacoemulsification. The quality effect model showed an IOPR weighted mean difference (WMD) of 1.22 mm Hg (confidence interval [CI]: [-0.43, 2.87]; Q = 315.64; p < 0.01; I2 = 97%) and decreased eye drops WMD 0.42 drops (CI: [0.22, 0.62]; Q = 42.6; p < 0.01; I2 = 84%) between both surgical groups. Subgroup analysis shows that the new generation iStent may be more effective in reducing IOP. CONCLUSION: iStent has a synergetic effect with phacoemulsification. The reduction of IOP and glaucoma eye drops was higher when iStent is combined with phacoemulsification compared with isolated phacoemulsification.

Cataract in keratoconus: Six-month results and a comparison of standard intraocular lens power calculation formulas.

PURPOSE: To report the results of cataract surgeries in keratoconus patients at 1 and 6 months postoperatively, and to compare the standard intraocular lens (IOL) calculation formulas in this population. METHODS: This is a retrospective study, carried out in 44 eyes of 26 patients known to have keratoconus who underwent cataract surgery at Beirut Eye and ENT Specialist Hospital between 2010 and 2021. The patients were divided into groups based on Dr Jarade updated algorithm. Visual acuities before and after cataract surgery, at 1 and 6 months were recorded, as well as spherical equivalent. The difference between the expected spherical equivalent with each formula was subtracted from the actual resultant refraction, and its absolute value deduced. The means of the values were calculated and the 4 standard formulas (SRK/T, SRK/II, Holladay, and Hoffer Q) were compared. RESULTS: Six eyes had similar topographic and manifest axes (category 1) and underwent toric IOL implantation. Corrected distance visual acuity (CDVA) at 1 and 6 months was 0.2 and 0.1 logMAR, respectively. 26 eyes had mismatching axes and had monofocal IOL placement. CDVA at 1 and 6 months was 0.3. Six eyes required intrastromal corneal ring placement before operating (category 3). CDVA was 0.3 and 0.2 at 1 and 6 months, respectively. Regarding category 4, requiring keratoplasty and cataract extraction, CDVA was 0.4 at both follow-ups. No statistically significant difference was found between the different formulas. CONCLUSION: Categorization of keratoconus patients gave favorable results after cataract surgery. No superior IOL formula was found.

Epidemiology of Ocular Malignancies Among the Lebanese Population: A 12-Year Review.

Purpose Our article aims to assess the epidemiology of eye cancer in Lebanon and compare it with other regions worldwide and to study its future trends among Lebanese males and females. Methods Data on eye cancer cases from 2005 to 2016 were obtained from the Lebanese National Cancer Registry (NCR). Age-specific rates, crude rates, and age-standardized rates (ASRs) were subsequently calculated. Joinpoint was used to determine the changes in the slope of trends. A projection for the next 14 years was predicted using linear and logarithmic regression models. Results Among all tumors, eye cancer ranked 40 in females and 41 in males. The eye cancer ASR was 0.24 and 0.22 per 100,000 in males and females, respectively. However, the mean age of eye cancer was 31.94 years in males and 22.04 years in females. The cumulative risk between 0 and 74 years was 0.02%. From 2004 till 2016, a negative trend of eye cancer was observed, with a parallelism of trends between males and females. Age-specific rates showed a bimodal distribution in males. The first cluster was witnessed in the age group of 0-4 years and the second one in those above 50. An additional cluster of distribution was observed in females between 35 and 44 years of age. Forecasts for the next 14 years revealed a steady rate of eye cancer incidence of about 0.2 per 100,000. Moreover, Lebanon showed a relatively low eye cancer ASR compared to other regions worldwide, especially Zimbabwe with 5.8 and 4.8 per 100,000 in females and males, respectively. Conclusion Ocular malignancies showed a negative trend of incidence. A 14-year projection predicts a steady incidence rate in Lebanon and worldwide. Eye cancer seems to be affected by many risk factors. Future efforts are needed for a better understanding of the disease and a better outcome.

Corneal Cross-Linking for Keratoconus and Post-LASIK Ectasia and Failure Rate: A 3 Years Follow-Up Study.

Purpose To report the response of keratoconus (KC) and post-LASIK ectasia (referred to as "ectasia") to the corneal crosslinking (CXL) and to compare the rate of progression between KC and ectasia at three years. Methods A retrospective cohort study of patients undergoing CXL for either KC or ectasia. Fifty-four eyes (31 patients) with ectasia and 111 eyes (67 patients) with KC were included in the study. Corrected distance visual acuities (CDVA), refraction, keratometry (K), and pachymetry were followed up for three years. Simultaneous photorefractive keratectomy (PRK) and CXL were performed on 20 KC and 20 ectasia eyes. Intrastromal Corneal Ring Segments (ICRS) were performed on 51 KC and six ectasia eyes. Results In KC, CDVA, spherical equivalence, sphere, cylinder, and mean K improved at three years post-CXL (p-value<0.05), but these values improved without reaching a statistical significance in ectasia(p-values <0.05). 12 of 54 eyes with ectasia (22.2%) and 4 of 111 eyes (3.6%) with KC had progression post CXL(p-value:0.0001). Ectasia patients diagnosed with progression were older at presentation (36.1 years) than non-progressive ectasia patients (31 years) (p-value 0.02) and also older than KC patients. Sub-analysis excluding PRK and ICRS cases showed that there was an improvement in mean sphere (from -5.23±4.2D to-4.46±3.89D) (p-value 0.03) cylinder (from 2.54 ± 1.68D to 1.97 ± 1.51D) (p-value 0.03) mean keratometry (from 46.81 ± 3.78D to 46.01 ± 3.25D) (p-value 0.006) in KC patients 3 years post CXL (40 patients). Compared to baseline, all the mean refractive and topographic variables deteriorated at three years post CXL in ectasia (28 patients) (p-value>0.05). Also, 2 of 40 patients with KC (5%) vs. 7 of 28 patients with ectasia (25%) had progression three years post-CXL, and the difference between both groups remained statistically significant(p-value 0.027). Conclusion Eyes with post-LASIK ectasia seem to be less responsive to CXL than KC.

Spontaneous Trabeculectomy Bleb Reformation and Regain of Function Following Phacoemulsification.

Phacoemulsification and cataract surgery in general often lead to trabeculectomy bleb failure. We herein describe an unusual occurrence in a 79-year-old female who had a failed trabeculectomy bleb for one year prior to presentation, and whose failed bleb became reformed, and she regained function on the first day post-phacoemulsification, manifesting as a decrease in intraocular pressure. Topical corticosteroids were used for one month postoperatively and the bleb remained functional over more than six months of follow-up. It is most likely that the intraocular pressure elevation that occurs during phacoemulsification was responsible for the reformation of the bleb, even after having been a failed bleb for a whole year.

Geographic Variation in Strabismus Pattern Among Pediatric Age Group in Lebanon: A Single-Centre Five-Year Observational Study.

BACKGROUND: Strabismus means ocular misalignment. It is also one of the most prevalent types of amblyopia and the leading cause of pediatric visual impairment. OBJECTIVE: This study aims to determine the frequency of different types of strabismus and the associated refractive errors and amblyopia in patients younger than 16 years of age. This study also aims to compare the age at presentation and gender between the geographic locations and between different strabismus types. MATERIALS AND METHODS: A cross-sectional retrospective study was done using the archives of Beirut Eye and ENT specialist hospital between January 2014 and December 2018. Lebanese pediatric patients aged <16 years having strabismus were included in this study. RESULTS: There was a total of 787 pediatric patients with strabismus, 62.6% of cases had esotropia (ET) and 30.2% exotropia (XT), with ET/XT: 2.07/1. Mt Lebanon had the highest number of cases, whereas Nabatieh was the only governorate with reversed ET/XT ratio. Most patients were diagnosed at the age of 1-5 years, with ET being the most common diagnosis, while XT was mostly found in patients aged 11-15. Hyperopia was the most common (55.4%) refractive error detected in our cohort of strabismus patients, followed by myopia and simple astigmatism. Amblyopia was found in 18.9% of cases, where Nabatieh had the highest count. CONCLUSION: Strabismus pattern was investigated for the first time across Lebanon to shed the light on the crucial role of early ophthalmologic examination, to detect early refractive error and strabismus, and to prevent amblyopia.

Incidence, Risk Factors and Treatment Outcomes of Intraocular Hypertension and/or Glaucoma Post-Penetrating Keratoplasty: A 5-Year Lebanese Retrospective Descriptive Study.

PURPOSE: Glaucoma is one of the most common complications post-penetrating keratoplasty (PK). In this study, we report the Incidence, risk factors and treatment outcomes of intraocular hypertension (IOH) or/and glaucoma post-penetrating keratoplasty (PKG). METHODS: A 5-year descriptive retrospective study, Lebanese patients who underwent PK at Beirut Eye & ENT Specialist Hospital, between 2012 and 2017, were included. Patients with history of glaucoma were excluded. IOH/PKG cases that necessitate treatment were identified and analyzed for the incidence, risk factors and treatment outcomes. RESULTS: A total of 189 eyes of 159 patients were included, with male/female ratio 1.6 and the mean age 47.2±21.3 years. Bullous keratopathy (BK) presented with a high mean age: 70.3 years while ectasia patients were the youngest: 36.5 years. 34.9% of eyes developed high IOP within a mean of 25 months of follow-up distributed between sub-groups of patient with corneal ectasia (22.5%), redo-PK (51.2%), bullous keratopathy (BK) (50%), keratitis (24.9%), and others (dystrophy, trauma …) (21.4%). High IOP developed in 67.4% of the diabetic patients. Visual acuity was less likely to improve in cases developing elevated IOP while postoperative complications were significantly high. In those refractory to medical treatment, trabeculectomy as a glaucoma surgery was effective in lowering the IOP. Combining procedures with PK was not a risk factor for glaucoma. Interrupted sutures and higher number of suturing were associated with increased IOP levels. CONCLUSION: IOH developed in one out of three patients who underwent penetrating keratoplasty. DM, bullous keratopathy, infectious keratitis and redo-PK were highly associated with PKG, whereas high IOP was less likely to develop in cases with keratoconus. Glaucoma is considered a poor prognostic factor in patients post-PK.

A Modified Customized Rigid Gas Permeable Contact Lens to Improve Visualization During Phacoemulsification in Ectatic Corneas.

Advanced Keratoconus and ectatic corneal diseases may lead to corneal thinning and irregular astigmatism. The optical distortion caused by these pathologies may result in poor visibility for the surgeon during phacoemulsification. Thus, the risk of complication would be increased intraoperatively (capsular rupture, vitreous loss). The aim of this case series was to use a modified customized Rigid Gas Permeable (RGP) contact lens to improve visualization during all the stages of phacoemulsification in irregular corneas and to avoid open sky technique for cataract removal during penetrating keratoplasty (PK). A customized, 12 mm, RGP contact lens was designed and manufactured. Two peripheral notches were customized to fit the hand position of the surgeon (at 11 O'clock and 2 Clock in this case series) to allow clear corneal incisions. Six eyes of 6 patients were included (3 eyes with advanced keratoconus and a severely optically distorted, yet clear corneas, planned for PK on the same day; 2 eyes were status post-intracorneal ring segment implantation for stage 4 keratoconus and 1 eye had combined phacoemulsification with superficial keratectomy to remove paracentral corneal Salzmann's nodule). Lens opacities ranged from +2 to +4 nuclear sclerosis in all eyes. Good visualization of the anterior lens and capsule attained with the RGP contact lens fitting. Improved visualization was reported during all the steps (Capsulorhexis, Irrigation/Aspiration, Phaco. Intraocular lens implantation). The phacoemulsification was smooth and non-complicated in a total of 6 eyes of 6 patients. In these cases, without RGP fitting, the operation was not technically possible. The customized notches allowed any insertion of surgical instruments, and with the help of viscoelastic maintained a good stability of the contact lens during the operation. We concluded that customized method RGP contact lens, may help reducing complications during phacoemulsification in advanced corneal ectasia and perhaps in irregular corneas as well.

Unilateral Malignant Glaucoma Postbilateral Implantable Collamer Lens: Effect of Miotics.

An implantable collamer lens® (ICL) V4c model (STAAR Surgical, Monrovia, CA, USA) was placed in the eye of a 31-year-old male patient with high myopia followed by the development of malignant glaucoma. After failing medical treatment for 5 days, a noncomplicated pars plana vitrectomy and anterior hyaloidectomy succeeded in breaking the aqueous misdirection. Sixteen months later, intraoperative miotics were purposefully withheld from the ICL surgery in the fellow eye and malignant glaucoma did not develop. Even though the patient's visual acuity postoperatively was 20/20, OU, a single small atrophic iris patch in the affected eye resulted in slightly more halos and glare in mesopic conditions as compared to the fellow eye. Earlier surgical intervention may have prevented iris ischemia and iridocorneal touch with its subsequent iris atrophy and resulted in an even more favorable visual outcome. Withholding intraoperative miotics during ICL surgery appeared to be beneficial in this case.

Management of cataract in keratoconus: early visual outcomes of different treatment modalities.

A review of 31 eyes with keratoconus who developed cataract and underwent phacoemulsification. Visual acuities were measured 1mo postoperatively. Six eyes with a history of good corrected distance visual acuity (CDVA) and a similar refractive and topographic astigmatic axis were implanted with toric intraocular lenses (IOLs). The mean postoperative uncorrected distance visual acuity (UDVA) was 0.2 logMAR with a spherical equivalent (SE): 0.75D. Eleven eyes with a history of good CDVA and different refractive and topographic axis were implanted with monofocal IOL+/-Toric implantable collamer lenses to treat anisometropia and ametropia; mean UDVA was 0.25 logMAR with a mean SE: -0.51 D postoperatively. Six eyes with poor CDVA were first treated with intra-corneal ring segments, followed by phacoemulsification, the mean postoperative UDVA was 0.82 logMAR with an SE: 0.22 D. Eight eyes had advanced ectesia and received combined phacoemulsification and penetrating keratoplasty. Our approach is efficient in addressing ametropia after cataract surgery in keratoconic eyes.

Biologic stromal ring to manage stromal melting after intrastromal corneal ring segment implantation.

We report a new technique to replace a manufactured poly(methyl methacrylate) (PMMA) ring with a biologic stromal ring fashioned from human corneal donor tissue in eyes with stromal melting above the PMMA ring. The biologic stromal ring is prepared using manual or femtosecond laser trephination of a donor cornea to obtain a 360-degree ring that is denuded and adjusted to match the PMMA ring being replaced. The biologic ring is attached to the PMMA ring. The PMMA ring is pushed and retrieved from the other side, which installs the biologic ring in place. Six biologic stromal rings were implanted successfully in 5 eyes of 5 patients with previous stromal melting; no complications were reported up to 6 months postoperatively. The biologic stromal ring stopped and healed the melting, prevented further ring complications, and preserved the therapeutic refractive effect of the previously implanted PMMA ring.

Late-Onset Sterile Peripheral Ulcerative Keratitis Post-Corneal Collagen Crosslinking.

PURPOSE: To report the incidence, characteristics, clinical presentations, risk factors, and the available treatment modalities of sterile peripheral ulcerative keratitis (PUK) post-corneal collagen crosslinking (CXL). METHODS: This study is a retrospective study including 771 eyes of 474 patients operated for keratoconus or ectasia after LASIK between January 2010 and June 2017 at Beirut Eye & ENT Specialist hospital. The average follow-up period was 4.2 years with a minimum of 1 year post-CXL. RESULTS: Eleven eyes (1.4%) of 8 patients developed late-onset PUK with or without corneal haze and sterile infiltrates. The complications occurred between 3 months and 6 years postoperatively. Their mean age of 39.6 ± 7.1 years was higher than the age of the noncomplicated patients 21.9 ± 8.8 years (P = 0.0001). Four affected patients had inflammatory and autoimmune conditions. Sex, presence of intrastromal ring segments, mean keratometry, and the thinnest pachymetry were found to be insignificantly different between groups, and photorefractive keratectomy was performed more in patients with keratitis. Duration of ultraviolet light exposure was related to sterile ulcerative keratitis development. All patients responded to steroid treatment, and only one had a relapse which resolved with topical cyclosporine 1% drops. CONCLUSIONS: PUK is a rare but serious complication after CXL. Long-term follow-up is necessary to detect late-onset PUK. It is a treatable condition associated with older age and autoimmune conditions but has a good visual outcome.

Third- and fourth-generation formulas for intraocular lens power calculation before and after phakic intraocular lens insertion in high myopia.

PURPOSE: To determine the effect of Visian Implantable Collamer Lens phakic intraocular lens (pIOL) insertion on biometric parameters and IOL power calculation. SETTING: Beirut Eye and ENT Specialist Hospital, Beirut, Lebanon. DESIGN: Prospective case series. METHODS: The IOLMaster 500 biometer was used to measure axial length (AL), keratometry (K), and anterior chamber depth (ACD) values before and 2 months after pIOL implantation. The IOL power was calculated using third-generation formulas (SRK/T, Holladay 1, Hoffer Q) and fourth-generation formulas (Haigis, Barrett Universal II). RESULTS: The study comprised 24 eyes (12 patients). The preoperative and postoperative AL were comparable (27.35 mm ± 1.51 [SD] versus 27.36 ± 1.6 mm; P = .91), as were the K values. There was a significant difference between the preoperative and postoperative ACD (3.67 ± 0.46 mm versus 3.4 ± 0.56 mm; P = .008). The mean IOL power calculation did not change significantly using the Haigis (10.04 ± 3.42 diopters [D] versus 10.1 ± 3.59 D; P = .69), SRK/T (9.85 ± 3.41 D versus 9.94 ± 3.58 D; P = .44), Holladay 1 (9.70 ± 3.47 D versus 9.80 ± 3.64 D; P = .45), Hoffer Q (9.70 ± 3.40 D versus 9.85 ± 3.59 D; P = .37), or Barrett Universal II (9.29 ± 3.52 D versus 9.35 ± 3.71 D; P = .63) formula. CONCLUSIONS: Phakic IOL insertion did not affect IOL power calculation. If preoperative data are not available, postoperative values can be used in IOL calculation formulas.

Severity of diabetic retinopathy at the first ophthalmological examination in the Lebanese population.

AIM: To determine the percentage and stage of diabetic retinopathy at the first ophthalmological examination after the patient's diagnosis with type 2 diabetes mellitus. METHODS: A retrospective descriptive study was conducted at 'Clinique du Levant' hospital between 2006 and 2016. A total of 484 randomly selected patients were included. Data were collected and analyzed for selected variables (sex, age, sources of referral, and duration of diabetes). RESULTS: In total, 119 (24.6%) patients had diabetic retinopathy. Among them, 43 had proliferative diabetic retinopathy (8.9%). About 16.7% of the included patients had macular edema, which was severe in 6.2%. The average age of patients was 62.1 years with an average of 8.3 years of diabetes. About 55% were men, while 45% were women. The patients with no referral source presented 8.9 years after the onset of diabetes, whereas patients referred by general practitioners and secondary medical professionals presented after 5.8 and 5 years, respectively (p < 0.05), but they represented only 23.2% of diabetics. Women presented earlier than men (7.3 versus 9.1 years; p = 0.012). About 82.6% were symptomatic, 44.1% had a visual impairment on Snellen charts that was severe in 11.2%. Also, 37.8% of the patients had a visually significant cataract. The duration of diabetes was the only dependent variable, p < 0.0001. The average age, sources of referral, and sex were not related to the severity of retinopathy. CONCLUSION: Diabetics with a more severe diabetic retinopathy are presenting late to the ophthalmology clinics. There is a need to promote outreach programs for people with diabetes for early detection of diabetic retinopathy in Lebanon.