Outcomes of Combination Therapy using Aflibercept and Dexamethasone Intravitreal Implant versus Dexamethasone Monotherapy for Macular Edema Secondary to Retinal Vein Occlusion.

PURPOSE: The purpose of this study was to evaluate the efficacy of the combination therapy of intravitreal aflibercept 2 mg (Eylea®) and a sustained-release dexamethasone 0.7 mg intravitreal implant (Ozurdex®) versus dexamethasone alone in providing better visual acuity in eyes with macular edema (ME) secondary to retinal vein occlusion (RVO). METHODS: Seventy-four eyes of 74 patients with treatment-naïve ME secondary to RVO were included in this prospective nonrandomized case series and were studied over a 12-month follow-up period. Patients in the dexamethasone monotherapy group were treated with an initial Ozurdex® injection while patients in the combination therapy group were treated with an Eylea® injection followed 2 weeks later by an Ozurdex® injection. The treatment was repeated as needed. Best-corrected visual acuity (BCVA), central macular thickness (CMT), and intraocular pressure were evaluated periodically. The primary outcome measure was the BCVA. The secondary outcome measures included CMT, number of retreatments, and safety parameters. RESULTS: At 1 year, the primary endpoint was met. Patients receiving combined therapy had better mean visual acuity changes from baseline compared to those receiving monotherapy (0.369 ± 0.221 logarithm of the minimum angle of resolution [logMAR] vs. 0.218 ± 0.171 logMAR; P = 0.002). The secondary endpoints were not met since there were no significant differences in mean reductions in CMT (272.67 ± 82.35 vs. 248.11 ± 159.73; P = 0.412) and the mean number of retreatments was similar in the two groups (1.75 ± 1.13 vs. 1.42 ± 0.64; P = 0.126). CONCLUSION: Aflibercept with dexamethasone implants achieved better visual outcomes compared to dexamethasone monotherapy with no significant differences in intravitreal retreatment rates at the 1st year in eyes with ME secondary to RVO.

KAMRA Inlay Implantation for Presbyopia Compensation: A Retrospective Evaluation of Patient Satisfaction and Subjective Vision 12-Month Postoperative.

PURPOSE: The aim of the study is to evaluate patients' satisfaction and subjective vision 12 months after monocular KAMRA corneal inlay implantation for the surgical compensation of presbyopia. SUBJECTS AND METHODS: Medical records of patients who underwent corneal inlay implantation in the nondominant eye between 2013 and 2014 were retrospectively reviewed. Data were collected from several centers in Lebanon. Patients with hyperopia or myopia with presbyopia between 45 and 70 years not suffering from any other ocular pathology were eligible for inclusion. Twelve-month postoperative satisfaction score was evaluated in all patients as well as the subjective vision score for near, intermediate, and distant tasks. RESULTS: This study included 73 patients. Almost 95% (69/73) of patients were satisfied or very satisfied with their vision and 93% (68/73) never or almost never used reading glasses while performing daily tasks. Subjective vision scores were found to be higher for distant and intermediate tasks performed during the day than for those performed during the night (P < 0.001). The average subjective vision score for reading a book or a newspaper in dim light was the lowest among all average subjective vision scores. No difference in satisfaction was found between patients with myopia or hyperopia or between males and females. CONCLUSION: The implant of a small-aperture corneal inlay resulted in a substantial improvement in patients' distant, intermediate, and near subjective vision, better in normal light than in dim light, and most patients became spectacles independent.

Regenerative Surgery of the Corneal Stroma for Advanced Keratoconus: 1-Year Outcomes.

PURPOSE: This study evaluated 1-year safety and efficacy outcomes of corneal stroma cell therapy. Therapy consisted of implanting autologous adipose-derived adult stem cells (ADASc) with or without sheets of decellularized donor human corneal stroma within the stroma of patients with advanced keratoconus. DESIGN: This was a prospective interventional non-randomized series of cases. METHODS: Fourteen consecutive patients were selected and divided into 3 experimental groups. Group A patients underwent implantation of autologous ADASc alone (3 × 106 cells/1 mL) (n = 5). Group B patients received decellularized donor 120-µm-thick corneal stroma lamina alone (n = 5). Group C patients had implantation of recellularized donor lamina with 1 × 106 autologous ADASc plus another 1 × 106 cells/1 mL at the time of the surgery (n = 4). Autologous ADASc were obtained by elective liposuction. Implantation was performed in the corneal stroma through a femtosecond-assisted 9.5-mm diameter lamellar dissection with the patient under topical anesthesia. Twelve months of follow-up data are presented. RESULTS: No complications were observed during the 1-year follow-up, and full corneal transparency was recovered within 3 months in all patients. No patient lost lines of visual acuity. Corrected distance visual acuity improved 0.231, 0.264, and 0.094 Snellen lines in groups 1, 2, and 3, respectively. In group 1, refractive parameters showed an overall stability, whereas in groups 2 and 3, sphere improved 2.35 diopter (D) and 0.625 D, respectively. Anterior keratometry remained stable (group 1) and improved in groups 2 and 3 (mean improvement of 2D). Corneal aberrometry improved significantly. In optical coherence tomography scans, corneal thickness showed a mean improvement of 14.5 µm (group 1) and 116.4 µm (groups 2 and 3) in the central thickness, and new collagen production was observed at the surgical plane (group 1). Confocal biomicroscopy confirmed the host recellularization of the implanted laminas. CONCLUSIONS: Intrastromal implantation of autologous ADASc and decellularized human corneal stroma did not show complications at 1 year of follow-up and were moderately effective for the treatment of advanced keratoconus. NOTE: Publication of this article is sponsored by the American Ophthalmological Society.

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.

Corneal Stroma Enhancement With Decellularized Stromal Laminas With or Without Stem Cell Recellularization for Advanced Keratoconus.

PURPOSE: This phase 1 study seeks to preliminarily evaluate the safety and efficacy of decellularized human corneal stromal lamina transplantation with or without autologous adipose-derived adult stem cell recellularization within the corneal stroma of patients with advanced keratoconus. DESIGN: Phase 1 clinical trial. METHODS: Femtosecond-assisted 120-µm thickness and 9-mm diameter laminas were obtained from the anterior stroma of human donor corneas and decellularized with a sodium dodecyl sulfate solution. Autologous adipose-derived adult stem cells were obtained by elective liposuction and cultured onto both sides of the lamina. Five patients received the decellularized lamina alone and 4 patients the recellularized lamina into a femtosecond-assisted 9.5-mm diameter lamellar pocket under topical anesthesia. The total duration of follow-up was 6 months. RESULTS: No case showed clinical haze or scarring by month 3. Six months after surgery, patients showed a general improvement of all visual parameters, with a mean unaided visual acuity from 0.109 to 0.232 (P = .05) and corrected distance visual acuity from 0.22 to 0.356 (P = .068). Refractive sphere improved in all patients (from -4.55 diopters [D] to -2.69 D; P = .017), but refractive cylinder remained stable (from -2.83 to -2.61; P = .34). An improvement tendency of all anterior keratometric values was observed. A mean improvement of 120 µm in all thickness parameters was confirmed (P = .008), as well as an improvement in the spherical aberration (P = .018), coma (P = .23) and total higher order aberrations (P = .31). No significant differences among groups were detected. CONCLUSIONS: Decellularized human corneal stromal laminas transplantation seems safe and moderately effective for advanced keratoconus. Potential benefits of its recellularization with autologous adipose-derived adult stem cells remains unclear.

Cellular Therapy With Human Autologous Adipose-Derived Adult Stem Cells for Advanced Keratoconus.

PURPOSE: The aim of this phase 1 study was to preliminarily evaluate the safety and efficacy of autologous adipose-derived adult stem cell (ADASC) implantation within the corneal stroma of patients with advanced keratoconus. METHODS: Five consecutive patients were selected. Autologous ADASCs were obtained by elective liposuction. ADASCs (3 × 10) contained in 1 mL saline were injected into the corneal stroma through a femtosecond-assisted 9.5-mm diameter lamellar pocket under topical anesthesia. Patients were reviewed at 1 day, 1 week, 1, 3, and 6 months postoperatively. Visual function, manifest refraction, slit-lamp biomicroscopy, intraocular pressure, endothelial cell density, corneal topography, corneal optical coherence tomography, and corneal confocal biomicroscopy were recorded. RESULTS: No intraoperative or postoperative complications were recorded, with full corneal transparency recovery within 24 hours. Four patients completed the full follow-up. All patients improved their visual function (mean: 1 line of unaided and spectacle-corrected distance vision and 2 lines of rigid contact lens distance vision). Manifest refraction and topographic keratometry remained stable. Corneal optical coherence tomography showed a mean improvement of 16.5 µm in the central corneal thickness, and new collagen production was observed as patchy hyperreflective areas at the level of the stromal pocket. Confocal biomicroscopy confirmed the survival of the implanted stem cells at the surgical plane. Intraocular pressure and endothelial cell density remained stable. CONCLUSIONS: Cellular therapy of the human corneal stroma in vivo with autologous ADASCs appears to be safe. Stem cells survive in vivo with intrastromal new collagen production. Future studies with larger samples are required to confirm these preliminary results.

Reluctance to screening colonoscopy in Arab Americans: a community based observational study.

To explore compliance of Arab-Americans to colorectal cancer (CRC) screening and identify the barriers for non-compliance. An observational community based study. Arab-American Friday prayer attendees' ≥50 years in three mosques in Dearborn, MI volunteered. Demographics, health insurance status, screening history, availability of a primary care physician (PCP) and the ability to communicate in Arabic were inquired. The responses were compared using a student t test between respondents who have had CRC screening with colonoscopy and those who have not had any screening tests. A p value of 0.05 or lower was considered statistically significant. Total number surveyed was 130. Average age is 64 years. Males were 76 % (99) and females 24 % (31). More than 50 % were Lebanese and 28 % were from Yemen. Majority had health insurance (89 %), and 86 % had a primary care physician of which 79 % of them spoke Arabic. Half of the participants had colonoscopy mostly for screening purposes. Fifty-eight (45 %) participants did not have CRC screening. Majority of the females (72.4 %) had colonoscopy compared to 46.8 % of the males (p value = 0.016). The mean length of stay in the U.S was 39.16 years in the colonoscopy group compared to 30.77 years in the non-screening group (p value = 0.006). Participants without a PCP did not have CRC screening (77.8 %) (p value = 0.005). Participants with a non-Arabic speaking PCP had more colonoscopy rates (77.3 %) compared to those with an Arabic speaking PCP (50 %) (p value = 0.027). More Lebanese had colonoscopy (71.9 %) compared to 25.7 % of the surveyed Yemenis (p value = 0.00). Discomfort, unawareness about CRC screening, and nonrecommendation by PCP were reported barriers. Arab-Americans have lower screening colonoscopy rates. Unfamiliarity of the importance of screening is a principal issue. Having a non-arabic speaking PCP is beneficial. Better education to this population about the benefits and ease of screening could increase adherence to screening for this population.

Health issues in the Arab American community. Managing cardiovascular risk barriers to optimal health outcomes in the Arab American patient.

Heart disease accounts for 38% of all deaths in the United States. The American Heart Association identified cardiovascular disease (CVD) as the most common cause of hospitalization in 2002. Direct and indirect costs of CVD have reached a total of $393.5 billion in 2005. Despite great advances in the treatment of CVD, high mortality rates and poor clinical outcomes persist. It has been estimated that a 17-year gap exists for research to reach clinical practice. More than half a million Americans of Arab ancestry live in Michigan. Similar to other ethnic groups, Arab Americans face challenges within the US healthcare system that hinder optimal clinical outcomes. Evidence-based studies targeting the Arab American population do not exist. Small observational studies provide limited data of questionable value.

A case of foot drop as an expression of brain metastases?

Foot drop can be defined as a significant weakness in ankle and toe dorsiflexion. Injury to the dorsiflexors or to any point along the neural pathways that supply these muscles can result in a foot drop. Injury to the peroneal nerve is usually the major precipitant. Other causes vary from trauma to surgical nerve injury, as well as leg compartment syndromes or dorsiflexor injuries, peripheral nerve injuries, stroke, neuropathies, drug toxicities, spinal stenosis, L5 sciaticas, systemic diseases such as connective tissue diseases, vasculidities, or diabetes. This report focuses on a patient presenting with a foot drop as an unusual manifestation of brain metastasis. His minimal symptomatology seemed to point towards a local process. Therefore, early recognition and prompt treatment are essential. The central nervous system must be the target of investigations when the workup fails to disclose the proper etiology. Potential diagnostic delays may occur. Certain cases may require a more aggressive approach.