Assessment of Learning Curve in Phacoemulsification Surgery Among the Eastern Province Ophthalmology Program Residents

Purpose

To assess residents’ performance of phacoemulsification surgery and determine which steps of the procedure are most difficult to learn, and to measure rate of intraoperative complications.

Design

This was a prospective observational study.

Methods

Phacoemulsification surgery was divided into steps and each step was given a proficiency grade by the attending consultant. All intraoperative complications were recorded and analyzed.

Results

200 cases performed by the Eastern Province ophthalmology program residents were evaluated. The most commonly encountered difficulty factors were hard nucleus (20.7%), small pupil (12.6%), and white cataract (10.3%). Capsulorhexis, nucleus disassembly and removal, and cortex removal were the most difficult steps to learn. General complication rate was 17.5%, and posterior capsular rupture was the most common complication (40%). Proficiency more than 90% of the time in each step was noted in residents with prior experience of more than 40 cases, except for nucleus disassembly.

Conclusion

The study showed that nucleus disassembly remained the major obstacle in the residents’ exponential learning curve of phacoemulsification surgery. Majority of complications occurred at level of capsulorhexis and cortical removal steps.

Acute Bacterial Endophthalmitis Following Dexamethasone Intravitreal Implant: A Case Report

A 54-year-old male presented to our ophthalmology clinic with a diagnosis of the right central retinal vein occlusion with macular edema. The patient was treated with dexamethasone intravitreal implant. Three days after the implant insertion, the patient experienced pain, redness and blurred vision in the same eye. With a provisional diagnosis of acute endophthalmitis, a combination of ceftazidime 2.25 mg/0.1 ml and vancomycin 1 mg/0.1 ml was injected intravitreally. One week after the treatment, endophthalmitis signs and symptoms subsided. This report presents a case of endophthalmitis following dexamethasone intravitreal implant, with a favorable outcome after treatment with intravitreal antibiotic injection without removal of the implant.

Optical coherence tomography patterns of diabetic macular edema in a Saudi population

Purpose: The study aims to describe the patterns of diabetic macular edema (DME) and their association with visual acuity using optical coherence tomography (OCT). Patients and methods: This is a retrospective observational study with chart review of patients with DME including both type 1 and 2 diabetics seen between January 2015 and January 2016. Main Outcome Measures: Type of diabetes, diabetes duration, best-corrected visual acuity, DME pattern, central macular thickness (CMT), and stage of diabetic retinopathy. DME was classified based on OCT scans into: sponge-like diffuse retinal thickness (SLDRT), cystoids macular edema (CME), and sub-retinal fluid (SRF). Results: 227 eyes (144 patients) were included. The SLDRT represented 67.84%, CME 19.82%, and presence of SRF 2.20%. OCT scan from 21 patients (22 eyes) displayed more than a single pattern. The CMT and visual acuities varied depending on the DME morphologic patterns. SLDRT was associated with the least affected mean visual acuity of 0.2±0.21. SRF signified the worst mean visual acuities. Increase in CMT significantly correlated with reduced visual acuity (P=0.005). A statistically significant positive correlations between diabetic stage-high risk proliferative diabetic retinopathy (PDR) and severe non-proliferative diabetic retinopathy (NPDR)-with the CMT (P=0.050) and (P=0.021) respectively, were observed. A significant positive correlation between the duration of diabetes, age and type 1 diabetes with visual acuity in LogMAR (P=0.003), (P=0.03), and (P=0.0005) respectively. Conclusions: SLDRT was the most common morphological subtype of DME patterns and increasing retinal thickness impaired the visual acuity. Older ages, longer diabetic duration and type 1 diabetes are considered significant risk factors for visual acuity impairment. The study also suggests that there is a significant correlation between the DME patterns and visual acuity.

Comparative study of visual dysfunctions in 6-10-year-old very preterm- and full-term-born children

PURPOSE

To compare visual dysfunction between very preterm-born (VPB) children with no retinopathy of prematurity (no-ROP) at 6-10 years of age and age- and sex-matched full-term-born controls.

METHODS

This is an observational, prospective study that included 30 children, 6-10 years of age, born ≤ 32 weeks of gestation, with no-ROP, and 30 age- and sex-matched full-term-born controls, conducted from January 2015 until August 2015. All children underwent complete ophthalmic evaluation. Main outcome measures include visual functions (best corrected visual acuity (BCVA), color vision, and stereoacuity), ocular alignment, refractive errors, and the presence of amblyopia and nystagmus.

RESULTS

Mean BCVA of the right eyes was 0.04 ± 0.08 logMAR for VPB children and 0.02 ± 0.05 logMAR for the full-term children (P = 0.075). Mean BCVA for the left eyes was 0.07 ± 0.09 logMAR for VPB children and 0.02 ± 0.05 logMAR for the full-term children (P = 0.014). Refractive errors were slightly higher though not statistically significant in VPB children compared to full-term children (P = 0.125). The incidence of myopia and hypermetropia was 16.7 and 40%, respectively, in VPB children and 10 and 23.3%, respectively, in full-term children. Anisometropia found only in VPB children with an incidence of 16.7%. Amblyopia found in 10% of VPB children compared to 3.3% in full-term children. Strabismus was found equally in 10% of each group.

CONCLUSION

VPB children with no-ROP are at an increased risk of developing decreased BCVA at least in one eye and anisometropia compared to age-matched full-term controls.

A healthy infant with bloody tears: Case report and mini-review of the literature

A 4-month old healthy infant was brought by her parents to the emergency department with bloody tears of three days duration. There was also intermittent yellowish discharge since birth and a history of flu-like symptoms a week prior to presentation. Extensive investigations revealed no infection or other possible etiologies. The patient was treated with antibiotic eye drops and her condition resolved within a three-four days.

In the literature, 15 cases with haemolacria of undermined source were reviewed; the median age of onset (12 years), bilateral involvement and female gender were more commonly encountered, and the most common associated illnesses were headache and epistaxis. The condition is self-limiting and spontaneous resolution is seen in majority of cases. Idiopathic haemolacria is a rare condition that can be presumed in patients presenting with bloody tears when all work-up turns to be negative. The condition is self-limiting with spontaneous resolution.

Recent developments in age-related macular degeneration: a review

Background

Visual impairment in elderly people is a considerable health problem that significantly affects quality of life of millions worldwide. The magnitude of this issue is becoming more evident with an aging population and an increasing number of older individuals.

Objective

The objective of this article was to review the clinical and pathological aspects of age-related macular degeneration (AMD), diagnostic tools, and therapeutic modalities presently available or underway for both atrophic and wet forms of the disease.

Methods

An online review of the PubMed database was performed, searching for the key words. The search was limited to articles published since 1980 to date.

Results

Several risk factors have been linked to AMD, such as age (>60 years), lifestyle (smoking and diet), and family history. Although the pathogenesis of AMD remains unclear, genetic factors have been implicated in the condition. Treatment for atrophic AMD is mainly close observation, coupled with nutritional supplements such as zinc and antioxidants, whereas treatment of wet AMD is based on targeting choroidal neovascular membranes.

Conclusion

Identification of modifiable risk factors would improve the possibilities of preventing the progression of AMD. The role of anti-vascular endothelial growth factor (anti-VEGF) agents has transformed the therapeutic approach of the potentially blinding disease “wet AMD” into a more favorable outcome.

Macular thickness in healthy Saudi adults. A spectral-domain optical coherence tomography study

Objectives:

To determine the macular thickness in the eyes of healthy Saudi adults using spectral-domain optical coherence tomography (SD-OCT).

Methods:

This is a prospective, cross-sectional study, including 158 healthy participants between August and December 2015. Mean subject age was 29.9 ± 7.85 years old. All participants underwent full ophthalmic evaluation, including SD-OCT imaging, and axial length measurement. Data from the right eye were included. Mean retinal thickness was determined. Correlations between retinal thickness and gender, age, axial length, and spherical equivalence were analyzed.

Results:

Mean central retinal thickness was 244.76 ± 23.62 µm, mean axial length was 23.8 ± 1.062 mm (range: 20.5-29 mm) and mean spherical equivalent was -0.31 ± 1.75 diopters (D) (range: -5.50 to +4.25 D). Central subfield (CSF) thickness and foveal volume were significantly lower in women than in men (both p<0.001). Data from the various age groups did not show statistically significant differences in the CSF thickness (p=0.389) or foveal volume (p=0.341). A positive correlation between CSF thickness and axial length (p<0.001) was observed.

Conclusion:

The normal macular thickness values in healthy Saudi individuals is different from that reported in other ethnic groups, as obtained by SD-OCT. Saudi men had thicker CSF than Saudi women and axial length was positively correlated to the central foveal thickness.

A Critical Role for Extracellular DNA in Dental Plaque Formation

Extracellular DNA (eDNA) has been identified in the matrix of many different monospecies biofilms in vitro, including some of those produced by oral bacteria. In many cases, eDNA stabilizes the structure of monospecies biofilms. Here, the authors aimed to determine whether eDNA is an important component of natural, mixed-species oral biofilms, such as plaque on natural teeth or dental implants. To visualize eDNA in oral biofilms, approaches for fluorescently stained eDNA with either anti-DNA antibodies or an ultrasensitive cell-impermeant dye, YOYO-1, were first developed using Enterococcus faecalis, an organism that has previously been shown to produce extensive eDNA structures within biofilms. Oral biofilms were modelled as in vitro "microcosms" on glass coverslips inoculated with the natural microbial population of human saliva and cultured statically in artificial saliva medium. Using antibodies and YOYO-1, eDNA was found to be distributed throughout microcosm biofilms, and was particularly abundant in the immediate vicinity of cells. Similar arrangements of eDNA were detected in biofilms on crowns and overdenture abutments of dental implants that had been recovered from patients during the restorative phase of treatment, and in subgingival dental plaque of periodontitis patients, indicating that eDNA is a common component of natural oral biofilms. In model oral biofilms, treatment with a DNA-degrading enzyme, NucB from Bacillus licheniformis, strongly inhibited the accumulation of biofilms. The bacterial species diversity was significantly reduced by treatment with NucB and particularly strong reductions were observed in the abundance of anaerobic, proteolytic bacteria such as Peptostreptococcus, Porphyromonas and Prevotella. Preformed biofilms were not significantly reduced by NucB treatment, indicating that eDNA is more important or more exposed during the early stages of biofilm formation. Overall, these data demonstrate that dental plaque eDNA is potentially an important target for oral biofilm control.

Corneal biomechanics in normal Saudi individuals

Purpose

The aim of this study was to determine and relate corneal biomechanical metrics with demographic, tomographic and refractive data in healthy Saudi people.

Design

Prospective, cross-sectional, observational study.

Participants

The study included 215 normal Saudi adult individuals.

Methods

Corneal hysteresis (CH) and corneal resistance factor (CRF), Goldmann-correlated intraocular pressure (IOPg) and corneal-compensated intraocular pressure (IOPcc) were measured by ocular response analyzer. The central keratometry (CK), central corneal thickness (CCT), and anterior chamber depth (ACD) were measured using Pentacam system. The spherical equivalent of refraction (SER) was obtained by an Auto-refractometer.

Results

The mean CH was 11.16 ± 2.11, CRF was 11.07 ± 2.31 and IOP was 15.12 ± 3.5. Mean CK, ACD, CH and CRF were distinct among gender with the significant P values of 0.05, 0.006, 0.020, and 0.047 respectively. CRF was negatively correlated with ACD (r = −0.146, P = 0.032). A positive correlation was found between CRF and SER (r = 0.176, P = 0.010), CCT (r = 0.447, p = 0.000) and CH (r = 0.878 and p = 0.000). CH was negatively correlated with IOPcc (−0.433, p = 0.000). A positive correlation was found between CH and ACD (r = −0.14, p = 0.044), SER (r = 0.617, p = 0.014), CCT (r = 0.412, p = 0.000) and IOPg (r = 0.183, p = 0.007).

Conclusion

This study demonstrated a distinct difference among gender values of corneal hysteresis and corneal resistance factor being higher in female Saudi subjects. CH and CRF values were higher in Saudi subjects than values in other populations. This may suggest the presence of ethnic differences in ocular parameters and support the importance of establishing population norms for corneal biomechanical parameters.

Bleb-related infection revisited: a literature review

Bleb-related infection (BRI) is one of the serious complications of glaucoma filtering surgery. This literature review is aimed at the evaluation of recent studies related to BRI. The review presented and discussed risk factors, and clinical and laboratory diagnosis emphasizing advances in diagnostic techniques to detect and distinguish the disease as well as to initiate immediate intensive antibacterial treatment. Clinical features of recognized prognostic factors of visual outcome were also presented. The studies showed that the prognosis of blebitis is usually good, unless infection has progressed to endophthalmitis that would signify a poorer prognosis. Despite prompt and intensive treatment of patients with bleb-related endophthalmitis, the outcomes remain unsatisfactory especially with virulent organisms and low initial visual acuity. It has been recommended that early detection and treatment of risk factors and thorough patient education are indispensable in ensuring best prognosis in post-trabeculectomy patients.

Age, gender and refractive error association with intraocular pressure in healthy Saudi participants: A cross-sectional study

Purpose

To determine the distribution of intraocular pressure (IOP) and its association with age, gender and refractive error in non-glaucomatous Saudi participants.

Design

Hospital-based cross-sectional observational study during Vision Day Screening Program. Participants: 458 participants living in the Al-Khobar, Saudi Arabia.

Methods

Recruited participants (aged 20 years or over) underwent a comprehensive questionnaire and ocular examination, including measurement of IOP with Perkins hand-held applanation tonometry and autorefraction.

Main outcome measures

The distribution of IOP of either of the eyes (right or left eye by randomization) and associations with age, gender and refractive error.

Results

Median IOP was 15.0 (range: 6–28) mmHg in the total population. There is no significant difference between the overall IOP of male participants, median 15 (range: 6–28) mmHg and female participants, median 16 (range: 6–28) mmHg (p = 0.180). No statistically significant difference in IOP in relation to age comparing 20–45 years group to 46–69 years group was documented (p = 0.751). There was no statistically significant relationship between refractive error category and IOP (p = 0.405). Ocular hypertension with IOP > 21 mmHg was found in 8.7% of the participants.

Conclusion

Variation in IOP by gender, age group and type of refractive error was not statistically significant. The observations need confirmation by study with larger sample representing Saudi population.

A clinic-based study of refractive errors, strabismus, and amblyopia in pediatric age-group

Purpose:

The purpose of this cross-sectional observational study was to determine the distribution and patterns of refractive errors, strabismus, and amblyopia in children seen at a pediatric eye care.

Materials and Methods:

The study was conducted in a Private Hospital in Dammam, Kingdom of Saudi Arabia, from March to July 2013. During this period, a total of 1350 children, aged 1–15 years were seen at this Center's Pediatric Ophthalmology Unit. All the children underwent complete ophthalmic examination with cycloplegic refraction.

Results:

Refractive errors accounted for 44.4% of the cases, the predominant refractive error being hypermetropia which represented 83%. Strabismus and amblyopia were present in 38% and 9.1% of children, respectively.

Conclusions:

In this clinic-based study, the focus was on the frequency of refractive errors, strabismus, and amblyopia which were considerably high. Hypermetropia was the predominant refractive error in contrast to other studies in which myopia was more common. This could be attributed to the criteria for sample selection since it was clinic-based rather than a population-based study. However, it is important to promote public education on the significance of early detection of refractive errors, and have periodic screening in schools.

Indications and techniques employed for keratoplasty in the Eastern province of Saudi Arabia: 6 years of experience

BACKGROUND AND OBJECTIVES

Keratoplasty services in Saudi Arabia have progressed steadily in the past few decades. We sought to identify the leading indications and types of keratoplasty performed in the Eastern Province of Saudi Arabia over a six-year period and to compare these indications with published data.

DESIGN AND SETTING

This was a retrospective descriptive analysis of the records of patients who underwent keratoplasty at four ophthalmology centers in the Eastern Province between 2008 and 2013.

PATIENTS AND METHODS

All keratoplasty procedures were included in the analysis. The primary surgical indication and type of surgery were identified for each case.

RESULTS

Keratoplasties included 570 penetrating keratoplasty, 217 deep lamellar keratoplasty, 80 triple procedures, 24 descemet stripping automated endothelial keratoplasty and 12 Boston keratoprosthesis implantations. The mean age of all patients was 28.8 years (range 14-72 years), and 58.9% of the patient were males. The lead.ing indication for keratoplasty was keratoconus 53.10%, bullous keratopathy 13.80%, corneal scarring 10.7%, regrafts 9.1%, and stromal dystrophies 4.9%.

CONCLUSIONS

In this study, the leading indications for keratoplasty were keratoconus, bullous keratopathy, corneal scarring, regrafts and stromal dystrophies. A significant increasing trend for descemet's stripping automated endothelial keratoplasty surgeries was observed in spite of the number of cases.

Macular and retinal nerve fiber thickness in recovered and persistent amblyopia

The aim of this study was to investigate the presence of increased macular or retinal nerve fiber layer thickness (RNFLT) in amblyopic eyes, find if the increased macular or RNFLT is related to the lack of response in amblyopic eyes, and to explore whether the increased central macular thickness (CMT) in amblyopic eyes is purely related to the hyperopia. This is a prospective descriptive study. CMT and peripapillary RNFLT were measured by spectral-domain optical coherence tomography to evaluate 60 patients with unilateral-treated amblyopia (median age 11.00 year). Patients were divided into two groups: 33 patients in recovered amblyopia group and 27 patients in persistent amblyopia group. The mean CMT in the recovered group was 247.31 (±23.4) versus 246.8 (±32.7) µm (p = 0.95) for the persistent group. The mean peripapillary RNFLT was 99.13 (±12.1) versus 99.9 (±14.9) µm (p = 0.85) for the persistent group. In anisometropic amblyopia, there was no significant difference in CMT and RNFLT in either group. Also there was no relation between the type of refractive error and CMT or RNFLT. There was no significant difference in CMT and RNFLT in amblyopic eyes for both the recovered amblyopia group and the persistent amblyopia group to explain the lack of response in persistent amblyopic eyes. Additionally there was no relation between the type of refractive error and CMT or peripapillary RNFLT.

Familial bilateral combined hamartoma of retina and retinal pigment epithelium associated with neurofibromatosis 1

We report a family of three siblings followed between 2005 and 2011 with bilateral combined hamartoma of the retina and retinal pigment epithelium, with the age of diagnosis ranging from 7 to 13 years. The main reason for consultation was reduction of vision and squint. The diagnosis was determined based on the clinical findings on fundus examination: increased pigmentation at the macula with slightly elevated, gray-white macular lesion, tortuosity of perimacular blood vessels and glial epiretinal membrane. The elder brother was found to have left posterior subcapsular cataract. He was also confirmed to have neurofibromatosis type 1, the youngest sister fit in the diagnostic criteria for neurofibromatosis type 1, while the middle sister was presumed to have neurofibromatosis type 1. Follow-up showed stability of the retinal lesion in the three cases, with the progression to develop right posterior subcapsular cataract in the elder sister. This report is aimed to demonstrate that the occurrence of bilateral combined hamartoma of the retina and retinal pigment epithelium could raise the possibility of associated neurofibromatosis.